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
Initiating the Hypoglycemia Protocol is necessary when the blood sugar is <70 mg/dL to quickly raise blood glucose levels.
Choice B rationale
No insulin is administered when blood sugar levels are between 70-130 mg/dL as it is within the normal range.
Choice C rationale
Administering 2 units of insulin for blood sugar levels between 131-180 mg/dL helps lower glucose to the normal range.
Choice D rationale
Administering 4 units of insulin for blood sugar levels between 181-240 mg/dL is necessary to reduce hyperglycemia.
Choice E rationale
Administering 6 units of insulin for blood sugar levels between 241-300 mg/dL addresses more severe hyperglycemia.
Choice F rationale
Administering 8 units of insulin for blood sugar levels between 301-350 mg/dL is used to manage significant hyperglycemia.
Choice G rationale
Administering 10 units of insulin for blood sugar levels between 351-400 mg/dL is crucial for severe hyperglycemia.
Choice H rationale
Administering 12 units of insulin and calling the physician for blood sugar levels >400 mg/dL is critical for immediate medical intervention.
Correct Answer is D
Explanation
Choice A rationale
Heavy lochia alba is an incorrect choice as lochia alba typically occurs after 10 days postpartum and is characterized by a whitish or yellowish discharge, not red.
Choice B rationale
Heavy lochia rubra is an incorrect choice because lochia rubra is characterized by bright red bleeding but heavy lochia would involve saturation of the pad within an hour, which is not the case here.
Choice C rationale
Moderate lochia serosa is incorrect because lochia serosa is typically pink or brown and occurs from approximately day 4 to day 10 postpartum, not red.
Choice D rationale
Scant lochia rubra is correct as the client is 3 days postpartum with red lochia measuring 2 cm on the pad, which indicates a small amount of bleeding consistent with scant lochia rubra.
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