A nurse is contributing to the care of a newborn who is experiencing hyperbilirubinemia and is receiving phototherapy.
Which of the following findings indicate that the phototherapy is effective?
Serum bilirubin level has increased from 6 hours ago.
Hemoglobin and hematocrit have increased.
Transcutaneous bilirubin (TcB) level has decreased from 6 hours ago.
Jaundice moves from chest to groin level.
The Correct Answer is C
Choice A rationale
An increase in serum bilirubin levels indicates worsening hyperbilirubinemia rather than improvement. Effective phototherapy should result in a decrease in bilirubin levels as it helps break down bilirubin into a form that can be excreted.
Choice B rationale
Hemoglobin and hematocrit levels are not directly affected by phototherapy. These values are more related to red blood cell count and do not indicate the effectiveness of phototherapy for treating hyperbilirubinemia.
Choice C rationale
A decrease in transcutaneous bilirubin (TcB) levels from 6 hours ago indicates effective phototherapy. Phototherapy reduces bilirubin levels in the blood by converting it to a water-soluble form that can be eliminated from the body.
Choice D rationale
Jaundice typically moves from the head to the lower body as bilirubin levels decrease. Movement from chest to groin level without a corresponding decrease in bilirubin levels does not necessarily indicate effective phototherapy. .
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale
Duchenne-Erb (Erb's) palsy is a type of brachial plexus injury that commonly results in an absent Moro reflex on the affected side, an extended arm at the elbow, and decreased grasp. These symptoms arise from injury to the fifth and sixth cervical nerves, leading to motor deficits.
Choice B rationale
This describes facial nerve palsy, not Erb's palsy. Facial nerve palsy affects the muscles of the face, leading to asymmetry during crying and drooping of the mouth's corner on the affected side.
Choice C rationale
While asymmetry of the Moro reflex is accurate, this choice incorrectly states that the arm is externally rotated and the grasp reflex is absent, which aligns more with a total brachial plexus injury rather than Erb's palsy.
Choice D rationale
Crepitus, no movement, swelling, and tenderness on palpation are indicative of a fracture rather than Erb's palsy. These symptoms suggest bone injury rather than nerve damage.
Correct Answer is A
Explanation
Choice A rationale
Respecting the client's decision to decline genetic testing upholds their autonomy and right to make informed decisions about their own healthcare.
Choice B rationale
Persistently attempting to schedule another appointment could be seen as pressuring the client, which may not be respectful of their initial decision.
Choice C rationale
Offering an appointment with a different genetic counselor may imply that the client's decision was not respected or understood, which can be perceived as dismissive.
Choice D rationale
Planning to perform genetic testing without the client's consent disregards their autonomy and the importance of informed consent in healthcare decisions.
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