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?
Blood glucose level will increase.
Transcutaneous bilirubin (TcB) level decreases.
Skin color changes from yellow to normal.
Weight gain is observed.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale
Decreased fetal heart rate can occur due to uteroplacental insufficiency but is not specific to hypertonic contractions.
Choice B rationale
The uterus may not relax between contractions, leading to a lack of rest periods for the fetus and compromised blood flow.
Choice C rationale
Easily indentable contractions are characteristic of hypotonic contractions, not hypertonic ones.
Choice D rationale
Weak and ineffective contractions indicate hypotonic labor, contrasting the excessive strength of hypertonic contractions.
NGN QUESTIONS
Correct Answer is A
Explanation
Choice A rationale
A boggy uterus indicates uterine atony, a leading cause of postpartum hemorrhage, as the uterus fails to contract effectively to compress blood vessels.
Choice B rationale
Moderate lochia rubra is expected postpartum vaginal bleeding, representing normal shedding of the uterine lining, not specifically indicating hemorrhage risk.
Choice C rationale
A first-degree perineal laceration is a minor tear that does not significantly increase the risk for postpartum hemorrhage as it usually involves limited bleeding.
Choice D rationale
Hypotension alone does not increase the risk for postpartum hemorrhage; however, it could be a result of ongoing hemorrhage rather than a cause.
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