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 C
Explanation
Choice A rationale
Advising a pregnant friend to get the varicella vaccine postpartum is correct as it is a live vaccine not recommended during pregnancy due to potential risks to the fetus.
Choice B rationale
If a person had chickenpox, they likely have immunity, but it's still beneficial to assess for varicella zoster immunity to determine if vaccination is necessary.
Choice C rationale
Varicella vaccine requires two doses, and misunderstanding this indicates a need for further teaching to ensure complete immunization and protection.
Choice D rationale
Planning to get the second dose at the pharmacy 12 weeks postpartum is correct, showing understanding of the vaccination schedule and follow-up care.
Correct Answer is D
Explanation
Choice A rationale
Rh positive clients with Rh positive newborns do not require Rho(D) immune globulin because there is no risk of Rh incompatibility.
Choice B rationale
If both the client and the newborn are Rh positive, Rho(D) immune globulin is not needed since there is no risk of the client developing antibodies against Rh positive cells.
Choice C rationale
Rh negative clients with Rh negative newborns also do not require Rho(D) immune globulin since there is no Rh positive blood to cause an immune response.
Choice D rationale
Rh negative clients with Rh positive newborns need Rho(D) immune globulin to prevent the client from developing antibodies against Rh positive blood, which could affect future pregnancies.
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