A nurse is caring for a newborn 4 hours after birth. Which of the following actions should the nurse include in the plan of care to prevent jaundice?

Prepare for an exchange blood transfusion.

Initiate early feeding.

Suction excess mucus with a bulb syringe.

Begin phototherapy.

Answer and Explanation

The Correct Answer is B

A.   Initiating early feeding helps promote the passage of meconium, which contains bilirubin, out of the newborn's body, reducing the risk of jaundice.

B.   Preparing for an exchange blood transfusion is not appropriate for preventing jaundice at this stage. Exchange transfusion is a treatment option for severe hyperbilirubinemia that has not
responded to other measures.
C.   Suctioning excess mucus with a bulb syringe is important for maintaining a patent airway in the newborn but does not directly prevent jaundice.
D.   Beginning phototherapy is a treatment for jaundice once it has occurred but is not a preventive measure.

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Correct Answer is B

Explanation

A. The ventrogluteal site can be used for IM injections in older infants but is not typically used in newborns.
B. The vastus lateralis muscle is the preferred site for IM injections in newborns due to its size and accessibility.
C. The dorso-gluteal site is not recommended for IM injections in infants due to the risk of injury to the sciatic nerve.
D. The deltoid muscle is not typically used for IM injections in newborns due to its small size and less developed musculature.

A. Absent plantar reflexes B. Lengthened thigh on the affected side C. Asymmetric thigh folds D. Inwardly turned foot on the affected side

Correct Answer is C

Explanation

A. Absent plantar reflexes may indicate neurological issues but are not specifically associated with developmental dysplasia of the hip (DDH).
B. Lengthened thigh on the affected side is not a typical finding in DDH. Instead, there may be apparent shortening due to hip dislocation.
C. Asymmetric thigh folds are a common finding in DDH due to hip instability, causing the femoral head to be displaced from the acetabulum and resulting in uneven thigh folds.

D. An inwardly turned foot on the affected side may be seen in conditions like clubfoot but is not a characteristic finding in DDH.

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A nurse is caring for a newborn 4 hours after birth. Which of the following actions should the nurse include in the plan of care to prevent jaundice?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is B

Explanation

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Correct Answer is C

Explanation

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