A nurse is caring for an infant who has a high Bilirubin level and is receiving phototherapy.

Which of the following is the priority finding in the newborn?

Conjunctivitis

Bronze discoloration of the skin

Sunken fontanelles

Maculopapular skin rash.

Answer and Explanation

The Correct Answer is C

This is a sign of dehydration, which can be caused by phototherapy. Phototherapy increases insensible water loss through the skin and can lead to fluid and electrolyte imbalance in the newborn. The nurse should monitor the newborn’s hydration status, weight, urine output, and serum electrolytes and provide adequate fluid intake.

Choice A is wrong because conjunctivitis is not a common complication of phototherapy. It can be prevented by using eye shields or patches to protect the newborn’s eyes from the light source.

Choice B is wrong because bronze skin discoloration is a rare complication of phototherapy that occurs when the bilirubin level is very high and the skin pigment changes. It is not a priority finding and usually resolves after phototherapy is discontinued.

Choice D is wrong because maculopapular skin rash is a benign side effect of phototherapy that does not require intervention. It usually disappears within a few days after phototherapy is stopped.

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Correct Answer is D

Explanation

Increased oxygen saturation.This indicates that the condition is improving because it means that the blood is getting more oxygen in the lungs and less blood is shunting from the aorta to the pulmonary artery through the patent ductus arteriosus (PDA).

Choice A is wrong because decreased heart rate can be a sign of hypoxia, acidosis, or heart failure, which are complications of PDA.

Choice B is wrong because increased blood pressure can be a sign of increased systemic vascular resistance, which can result from decreased tissue perfusion due to PDA.

Choice C is wrong because decreased respiratory rate can be a sign of respiratory depression, which can be caused by some medications used to treat PDA, such as indomethacin or ibuprofen.

Normal ranges for oxygen saturation in preterm infants are between 88% and 95%.

Normal ranges for heart rate in preterm infants are between 120 and 160 beats per minute.

Normal ranges for blood pressure in preterm infants depend on gestational age and weight.

Normal ranges for respiratory rate in preterm infants are between 40 and 60 breaths per minute.

A. Monitor blood glucose levels every hour until stable. B. Administer glucagon subcutaneously as prescribed. C. Discontinue IV dextrose when blood glucose reaches 60 mg/dL. D. Feed breast milk or formula every four hours.

Correct Answer is A

Explanation

This is because hypoglycemia in newborns can cause seizures, brain damage, and developmental delays, and frequent monitoring can help detect and correct low blood glucose levels promptly.

Some additional information about the other choices are:

Choice B. Administer glucagon subcutaneously as prescribed.This is wrong because glucagon is used to treat hypoglycemia caused by hyperinsulinism, which is a rare condition in newborns.Most cases of hypoglycemia in term infants are due to transient factors such as delayed feeding, maternal diabetes, or perinatal stress.

Choice C. Discontinue IV dextrose when blood glucose reaches 60 mg/dL.This is wrong because 60 mg/dL is still below the normal range of blood glucose for newborns, which is 70 to 100 mg/dL.Discontinuing IV dextrose too early can cause rebound hypoglycemia and increase the risk of neurologic complications.

Choice D. Feed breast milk or formula every four hours.This is wrong because feeding every four hours may not be enough to maintain adequate blood glucose levels in newborns with hypoglycemia.Infants with hypoglycemia should be fed more frequently, such as every two to three hours, or on demand.Breast milk or formula can also be supplemented with IV dextrose if needed.

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A nurse is caring for an infant who has a high Bilirubin level and is receiving phototherapy. Which of the following is the priority finding in the newborn?

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Naxlex Comprehensive Predictor Exams

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Correct Answer is D

Explanation

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Correct Answer is A

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A nurse is caring for an infant who has a high Bilirubin level and is receiving phototherapy.

Which of the following is the priority finding in the newborn?