A nurse is caring for a newborn in the neonatal unit. The newborn was delivered via cesarean birth approximately 1 hour ago. Below are the exhibits.
Complete the diagram by dragging from the choices below to specify:
- What condition the newborn is most likely experiencing.
- Two actions the nurse should take to address that condition.
- Two parameters the nurse should monitor to assess the newborn’s progress.
The Correct Answer is []
Condition: Neonatal Jaundice.
2 actions:
Initiate phototherapy,
Encourage frequent breastfeeding or formula feeding.
2 parameters:
Serum bilirubin levels,
Blood glucose levels.
Rationale for correct condition: Neonatal jaundice is indicated by the elevated bilirubin levels and yellow discoloration of the skin and sclera. The newborn's symptoms of lethargy, decreased muscle tone, and poor feeding are consistent with jaundice. Jaundice is common in newborns and requires prompt treatment to prevent complications like kernicterus. The total bilirubin level of 15 mg/dL is significantly elevated and needs intervention.
Rationale for actions: Initiating phototherapy helps lower bilirubin levels by breaking down bilirubin in the skin. This treatment is effective and commonly used for neonatal jaundice. Encouraging frequent breastfeeding or formula feeding promotes regular bowel movements, which help eliminate bilirubin from the body. Adequate feeding is essential to reduce jaundice severity. Administering intravenous dextrose addresses hypoglycemia but does not directly treat jaundice. Performing a lumbar puncture is unnecessary unless sepsis is suspected. Naloxone is used for opioid withdrawal, not jaundice.
Rationale for parameters: Monitoring serum bilirubin levels tracks the effectiveness of phototherapy. This parameter is crucial for assessing jaundice severity and treatment response. Blood glucose levels should be monitored due to the initial low reading, ensuring the newborn's glucose levels stabilize. Respiratory rate is normal and not directly related to jaundice. Urine output monitors hydration but is less specific to jaundice. Heart rate is stable and not a primary focus.
Rationale for incorrect conditions: Neonatal hypoglycemia focuses on low blood glucose but doesn't explain jaundice. Neonatal sepsis presents with more systemic signs like fever or abnormal reflexes. Neonatal abstinence syndrome involves withdrawal symptoms from maternal substance use, not relevant here.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["C","D","E"]
Explanation
Choice A rationale
A fundus midline and firm at the umbilicus is a normal postpartum finding and does not require reporting. It indicates that the uterus is contracting as expected to prevent postpartum hemorrhage.
Choice B rationale
Moderate lochia rubra without clots is expected in the immediate postpartum period and does not need to be reported. It is part of normal postpartum bleeding as the uterus sheds its lining.
Choice C rationale
A constant trickle of blood at the vagina postpartum could indicate a laceration or retained placental fragments and should be reported to the provider for further evaluation and management.
Choice D rationale
Hemoglobin levels can provide important information about the mother's blood loss during delivery. A low hemoglobin level could indicate significant blood loss and necessitates reporting.
Choice E rationale
An abnormal heart rate in a postpartum mother could be indicative of complications such as hemorrhage or infection and should be reported to the provider for further assessment.
Correct Answer is B
Explanation
Choice A rationale
Keeping the baby's bassinet away from fans is good practice to avoid drafts that could make the baby cold. Maintaining a stable environment is important for newborns to help regulate their body temperature effectively.
Choice B rationale
Checking the baby's temperature rectally every 3 hours is unnecessary and potentially harmful. Rectal temperature checks are invasive and not typically needed unless directed by a healthcare provider. Axillary temperature is safer and more commonly recommended.
Choice C rationale
Keeping the baby's head covered can help maintain body temperature, especially in cooler environments. Newborns can lose heat quickly through their heads, so this practice is beneficial to keep them warm.
Choice D rationale
Placing the baby on the stomach and covering with a warm blanket is not recommended for sleeping due to the risk of sudden infant death syndrome (SIDS). Babies should be placed on their backs to sleep to reduce this risk. .
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