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 C
Explanation
Choice A rationale
Applying a 1-2 cm ribbon from outer to inner canthus is incorrect because it increases the risk of contamination and infection by moving from a less clean area to a more clean area.
Choice B rationale
Applying a 2-3 inch ribbon from inner to outer canthus is incorrect because the length of the ribbon is too long and the direction is not recommended for preventing contamination.
Choice C rationale
Applying a 1-2 cm ribbon from inner to outer canthus is correct as it minimizes the risk of contamination by moving from a cleaner area to a less clean area, ensuring proper application of the ointment.
Choice D rationale
Applying a 1-2 inch ribbon to the upper eyelid is incorrect because the upper eyelid is not the recommended site for application, and the length of the ribbon is too long.
Correct Answer is {"A":{"answers":"A"},"B":{"answers":"B"},"C":{"answers":"A"},"D":{"answers":"A"},"E":{"answers":"A"}}
Explanation
- “The glans penis will appear red and have a yellow crust as it heals. Do not remove this.”
- Essential: This is a normal part of the healing process.
- “Ensure the diaper is really tight to keep the gauze attached to the penis.”
- Contraindicated: The diaper should be loose to avoid pressure on the circumcision site.
- “Notify your pediatrician if your baby has not voided in 24 hours.”
- Essential: This could indicate a problem that needs medical attention.
- “Coat the glans penis with petroleum jelly and cover with gauze.”
- Essential: This helps prevent the diaper from sticking to the circumcision site and aids in healing.
- “Check for bleeding every 4 hours for the first 24 hours and notify your pediatrician if there is bleeding at the circumcision site.”
- Essential: Monitoring for bleeding is crucial to ensure there are no complications.
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