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

Initiate early feeding.

Suction excess mucus with a bulb syringe.

Prepare for an exchange blood transfusion.

Begin phototherapy.

Answer and Explanation

The Correct Answer is A

A) Initiate early feeding:

Early and frequent breastfeeding or formula feeding helps stimulate bowel movements, which aid in the elimination of bilirubin from the body. Breast milk also contains substances that promote bilirubin excretion, making early feeding an effective preventive measure against neonatal jaundice.

B) Suction excess mucus with a bulb syringe:

While clearing excess mucus can facilitate breathing and feeding, it does not directly prevent jaundice.

C) Prepare for an exchange blood transfusion:

Exchange transfusion is a treatment option for severe jaundice that has not responded to other measures. It is not a preventive measure.

D) Begin phototherapy:

Phototherapy is a treatment for jaundice after it has occurred, not a preventive measure. It involves exposing the newborn's skin to specific wavelengths of light to break down excess bilirubin.

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Correct Answer is A

Explanation

A) 48/min:

A respiratory rate of 48 breaths per minute is within the expected reference range for a newborn. The normal range for respiratory rate in newborns is typically between 30 to 60 breaths per minute.

B) 100/min:

A respiratory rate of 100 breaths per minute is above the expected reference range for a newborn. While newborns may exhibit slightly elevated respiratory rates, a rate of 100 breaths per minute is higher than usual and may warrant further assessment.

C) 22/min:

A respiratory rate of 22 breaths per minute is below the expected reference range for a newborn. Normal respiratory rates for newborns are typically higher than 22 breaths per minute.

D) 110/min:

A respiratory rate of 110 breaths per minute is significantly above the expected reference range for a newborn. Such a high respiratory rate may indicate respiratory distress or another underlying issue and requires prompt assessment and intervention.

A. "I'll make sure his diaper is loose in the front." B. "I'll apply petroleum jelly to his penis with diaper changes." C. "I'll expect the plastic ring to fall off by itself within a week." D. "I'll call the doctor if I see any bleeding." E. "I'll wash his penis with warm water and mild soap each day."

Correct Answer is ["A","C","D"]

Explanation

A) "I'll make sure his diaper is loose in the front":

This statement indicates understanding because ensuring a loose diaper helps prevent irritation and discomfort to the healing circumcision site. Tight diapers can rub against the area and cause irritation or disrupt the healing process.

B) "I'll apply petroleum jelly to his penis with diaper changes":

While applying petroleum jelly to the penis with diaper changes is a common practice for circumcision care, it is not recommended for the Plastibell technique. Using petroleum jelly can interfere with the plastic ring and may prevent it from falling off naturally.

C) "I'll expect the plastic ring to fall off by itself within a week":

This statement indicates understanding because with the Plastibell technique, the plastic ring is left in place until it falls off on its own, typically within a week after the procedure. It is essential for the client to be aware of this expected outcome.

D) "I'll call the doctor if I see any bleeding":

This statement indicates understanding because it shows recognition of the potential complication of bleeding post-circumcision. While some minor bleeding may occur initially, excessive bleeding should be reported to the doctor promptly for further evaluation and management.

E) "I'll wash his penis with warm water and mild soap each day":

While keeping the area clean with warm water and mild soap is generally recommended for circumcision care, with the Plastibell technique, it is typically advised to avoid washing the area directly until the plastic ring falls off. Direct washing may interfere with the healing process or disrupt the plastic ring. Therefore, this statement does not indicate understanding of circumcision care with the Plastibell technique.

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A nurse is caring for a newborn 4 hr 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

A nurse is assessing a newborn 1 hr after birth. Which of the following respiratory rates is within the expected reference range for a newborn?

Correct Answer is A

Explanation

A nurse on a postpartum unit is giving discharge instructions to a client whose newborn had a circumcision with the Plastibell technique. Which of the following client statements indicates understanding of circumcision care? (Select all that apply.)

Correct Answer is ["A","C","D"]

Explanation

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