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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. Using a basin during bathing is a safe practice to prevent accidental slips or falls.
B. Testing the water temperature before bathing is essential to prevent burns or scalds.
C. Baby powder is not recommended for preventing diaper rash as it can contribute to respiratory issues when inhaled by the baby and has been associated with an increased risk of respiratory
problems and infections.
D. Using mild soap is appropriate for newborn skin to prevent irritation.
Correct Answer is B
Explanation
A. Pain following a cesarean birth is important to address, but it may not indicate an urgent need for assessment compared to other potential complications.
B. A client with preeclampsia requires close monitoring of blood pressure to prevent
complications such as eclampsia, which can lead to seizures and other serious consequences. An elevated blood pressure reading warrants immediate attention.
C. A client scheduled for discharge following a laparoscopic tubal ligation is stable and can likely wait for assessment until after higher-priority clients have been seen.
D. While it's important to monitor for bleeding after a vaginal birth, the absence of bleeding reported by a client 24 hours postpartum may not indicate an immediate need for assessment compared to the potential urgency of managing preeclampsia.
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