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 A
Explanation
Choice A rationale
Drying the newborn’s skin thoroughly immediately after birth helps reduce heat loss by evaporation, which is a significant concern as wet skin can cause rapid heat loss.
Choice B rationale
Maintaining ambient room temperature at 24°C (75°F) helps prevent heat loss by convection but does not directly address evaporation.
Choice C rationale
Placing the newborn on a warm surface helps prevent heat loss by conduction but does not address evaporation.
Choice D rationale
Preventing air drafts helps reduce heat loss by convection but does not address evaporation.
Correct Answer is A
Explanation
Choice A rationale
Placing a baby on their back to sleep significantly reduces the risk of SIDS. This position helps keep the airway open and reduces the risk of suffocation.
Choice B rationale
There is no direct correlation between SIDS and the diphtheria, tetanus, and pertussis vaccines. Vaccines are safe and do not increase the risk of SIDS3.
Choice C rationale
SIDS rates have actually decreased over the last 10 years, largely due to public health campaigns promoting safe sleep practices.
Choice D rationale
Sleep apnea is not the main cause of SIDS. The exact cause of SIDS is unknown, but it is believed to be related to defects in the brain that control breathing and arousal from sleep.
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