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A nurse is caring for a newborn who is experiencing hyperbilirubinemia and is receiving phototherapy. Which of the following findings indicate that the phototherapy is effective?

A.

Blood glucose level will increase.

B.

Transcutaneous bilirubin (TcB) level decreases.

C.

Skin color changes from yellow to normal.

D.

Weight gain is observed.

Answer and Explanation

The Correct Answer is B

Choice A rationale

Blood glucose level changes are unrelated to hyperbilirubinemia and phototherapy, which specifically target bilirubin metabolism in the newborn's liver and skin.

Choice B rationale

A decrease in transcutaneous bilirubin (TcB) levels shows effective phototherapy, as it converts bilirubin into water-soluble isomers that can be excreted.

Choice C rationale

Skin color changes from yellow to normal indicate reduced bilirubin levels, but the most accurate measure of phototherapy efficacy is the decrease in TcB levels.

Choice D rationale

Weight gain is not an indicator of effective phototherapy; it reflects overall nutrition and hydration status rather than bilirubin metabolism and excretion.


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Related Questions

Correct Answer is C

Explanation

Choice A rationale

While taking antipsychotics is important, the nurse’s immediate priority should be to assess for harm to the patient or infant, which poses an immediate danger.

Choice B rationale

Monitoring the infant’s health is important but secondary to ensuring the patient and infant's immediate safety from potential harm due to psychosis.

Choice C rationale

Assessing thoughts of harm is crucial in postpartum psychosis as it helps in identifying immediate risks to the patient and infant, allowing for timely interventions.

Choice D rationale

Reviewing the medical record for bipolar disorder is important for treatment planning but not as immediately critical as assessing for thoughts of harm.

Correct Answer is {"A":{"answers":"A,B"},"B":{"answers":"A,B"},"C":{"answers":"A,B"},"D":{"answers":"A,B"},"E":{"answers":"A,B"},"F":{"answers":"A,B"},"G":{"answers":"A"},"H":{"answers":"B"}}

Explanation

  1. Jittery Extremities
    • Hypoglycemia: Jittery extremities are a common sign of low blood glucose levels.
    • Neonatal Abstinence Syndrome: Jitteriness can occur due to withdrawal symptoms in newborns exposed to opioids.
  2. Poor Sucking Reflex
    • Hypoglycemia: Newborns with low blood glucose levels may have difficulty feeding and a poor sucking reflex.
    • Neonatal Abstinence Syndrome: Poor feeding and sucking reflex can be part of withdrawal symptoms in newborns.
  3. Excessive Sweating
    • Hypoglycemia: Excessive sweating can be a symptom of low blood glucose levels.
    • Neonatal Abstinence Syndrome: Sweating is one of the possible signs of withdrawal in newborns.
  4. Irritability
    • Hypoglycemia: Irritability can result from low blood glucose levels.
    • Neonatal Abstinence Syndrome: Irritability is a common symptom of withdrawal in newborns exposed to opioids.
  5. Weak Cry
    • Hypoglycemia: A weak cry can be a symptom of low blood glucose levels.
    • Neonatal Abstinence Syndrome: Weak cry can also be part of withdrawal symptoms in newborns.
  6. Mild Tremors
    • Hypoglycemia: Tremors or shaking can be a sign of low blood glucose levels.
    • Neonatal Abstinence Syndrome: Tremors are common withdrawal symptoms in newborns exposed to opioids.
  7. Low Blood Glucose Level
    • Hypoglycemia: A blood glucose level of 40 mg/dL is considered low and indicates hypoglycemia.
    • Neonatal Abstinence Syndrome: Low blood glucose level is not a direct indicator of NAS but may occur due to poor feeding.
  8. Positive Urine Toxicology
    • Hypoglycemia: Not relevant.
    • Neonatal Abstinence Syndrome: Positive urine toxicology for opioids indicates in utero exposure to opioids, which can lead to NAS.

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