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 A
Explanation
Choice A rationale
Anticonvulsants can induce liver enzymes, increasing the metabolism of combined oral contraceptives (COCs) and reducing their effectiveness.
Choice B rationale
Antihypertensives do not have a significant impact on the effectiveness of COCs.
Choice C rationale
Antioxidants do not interfere with the metabolism or effectiveness of COCs.
Choice D rationale
Antibiotics, except for rifampin, typically do not reduce the effectiveness of COCs.
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.
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