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A nurse is creating a plan of care for a newborn who is breastfed and appears jaundiced.

Which of the following interventions should the nurse include?

Place the newborn under a radiant warmer.

Supplement breastfeeding with iron-fortified formula.

Determine the effectiveness of breastfeeding.

Administer Rho(D) immune globin to the newborn.

Answer and Explanation

The Correct Answer is C

Choice A rationale:

Placing the newborn under a radiant warmer is not directly related to addressing breastfeeding-related jaundice.

Choice B rationale:

Supplementing breastfeeding with formula is not the first-line approach and may interfere with establishing successful breastfeeding.

Choice C rationale:

Breastfeeding-related jaundice can occur if the newborn is not effectively breastfeeding and not getting enough milk. Assessing the effectiveness of breastfeeding is important to address the underlying cause of jaundice.

Choice D rationale:

Administering Rho(D) immune globulin is unrelated to addressing jaundice in a breastfed newborn.

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Correct Answer is C

Explanation

Choice A rationale:

Awakening the client frequently throughout the day is not necessary and can disturb their rest and comfort.

Choice B rationale:

Using an electric blanket can increase the risk of burns or overheating in a client who is approaching death and may have reduced ability to regulate body temperature.

Choice C rationale:

Positioning the client on their side with the head of the bed elevated can facilitate drainage of respiratory secretions, maintain airway patency, and provide comfort.

Choice D rationale:

Encouraging the client to eat soft foods intermittently may not be relevant, as the client's ability to eat and swallow may be limited in the end stages of life.

A. A client who developed influenza after receiving the vaccine last year B. A client who has hypertension C. A client who has a history of Guillain-Barré syndrome D. A client who has an allergy to dairy products.

Correct Answer is C

Explanation

Choice A rationale:

Developing influenza after receiving the vaccine the previous year is not a contraindication for receiving the vaccine this year. In fact, the vaccine is recommended annually.

Choice B rationale:

Hypertension is not a contraindication for receiving the influenza vaccine.

Choice C rationale:

Clients with a history of Guillain-Barré syndrome should generally avoid receiving the influenza vaccine due to a potential increased risk of recurrence of the syndrome.

Choice D rationale:

Allergies to dairy products are not a contraindication for receiving the influenza vaccine.

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A nurse is creating a plan of care for a newborn who is breastfed and appears jaundiced. Which of the following interventions should the nurse include?

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A nurse is creating a plan of care for a newborn who is breastfed and appears jaundiced.

Which of the following interventions should the nurse include?