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?
Monitor blood glucose levels frequently.
Begin phototherapy immediately.
Initiate early feeding.
Prepare for a blood transfusion.
The Correct Answer is C
Choice A rationale
Monitoring blood glucose levels frequently is important for newborns, especially those at risk for hypoglycemia. However, it does not directly prevent jaundice. Jaundice is caused by elevated bilirubin levels, which are not directly related to blood glucose levels.
Choice B rationale
Beginning phototherapy immediately is a treatment for jaundice, not a preventive measure. Phototherapy is used to reduce high bilirubin levels in newborns who already have jaundice.
Choice C rationale
Initiating early feeding is an effective way to prevent jaundice in newborns. Early feeding helps promote regular bowel movements, which aids in the excretion of bilirubin from the body, thereby reducing the risk of jaundice.
Choice D rationale
Preparing for a blood transfusion is a treatment for severe jaundice, not a preventive measure. Blood transfusions are used in cases of extreme hyperbilirubinemia that do not respond to other treatments.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["D","F","G","H"]
Explanation
Choice A rationale
Flexion of arms is a normal finding in newborns and does not indicate respiratory distress.
Choice B rationale
Caput succedaneum is a common condition where the scalp swells due to pressure during delivery. It does not indicate respiratory distress.
Choice C rationale
A heart rate of 158 bpm is within the normal range for newborns and does not indicate respiratory distress.
Choice D rationale
A respiratory rate of 66/min is above the normal range (30-60 breaths per minute) and indicates respiratory distress.
Choice E rationale
Acrocyanosis is common in newborns and does not indicate respiratory distress.
Choice F rationale
Subcostal retractions indicate increased work of breathing and are a sign of respiratory distress.
Choice G rationale
Nasal flaring is a sign of respiratory distress as it indicates increased effort to breathe.
Choice H rationale
Grunting is a sign of respiratory distress as it indicates difficulty in maintaining lung expansion.
Correct Answer is B
Explanation
Choice A rationale
Small for gestational age (SGA) refers to newborns whose birth weight is below the 10th percentile for their gestational age.
Choice B rationale
Appropriate for gestational age (AGA) refers to newborns whose birth weight is between the 10th and 90th percentiles for their gestational age. A newborn weighing 3350 g at 39 weeks gestation falls within this range.
Choice C rationale
Low birth weight is defined as a birth weight of less than 2500 g, which does not apply to this newborn.
Choice D rationale
Large for gestational age (LGA) refers to newborns whose birth weight is above the 90th percentile for their gestational age.
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