A nurse is evaluating a newborn who has hyperbilirubinemia and is receiving phototherapy.
Which of the following outcomes indicates that the therapy is effective?
The newborn’s skin color is pink
The newborn’s stools are clay-colored
The newborn’s bilirubin level is 12 mg/dL
The newborn’s urine is dark yellow.
The Correct Answer is A
The newborn’s skin color is pink. This indicates that the phototherapy is effective in lowering the serum bilirubin level by transforming it into water-soluble isomers that can be eliminated without liver conjugation.
A pink skin color also means that the newborn is not jaundiced, which is a sign of high bilirubin levels.
Choice B is wrong because clay-colored stools indicate a problem with the liver or bile ducts. Bile is needed to give stools their normal brown color, and if bile is absent or blocked, the stools may become pale or clay-colored. This could be a sign of a serious condition such as biliary atresia, which is a congenital defect that causes bile ducts to be absent or malformed.
Choice C is wrong because a bilirubin level of 12 mg/dL is still high for a newborn and may require further treatment. The American Academy of Pediatrics recommends phototherapy for newborns with bilirubin levels above 15 mg/dL at 25 to 48 hours of age, 18 mg/dL at 49 to 72 hours of age, and 20 mg/dL at more than 72 hours of age. However, these thresholds may vary depending on the gestational age, risk factors, and clinical condition of the newborn.
Choice D is wrong because dark yellow urine may indicate dehydration or concentrated urine, which can increase the risk of bilirubin toxicity. Newborns receiving phototherapy should be well hydrated and have frequent wet diapers to help eliminate bilirubin from the body. Normal urine color for a newborn is pale yellow or clear.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
This is because the infant born through meconium-stained amniotic fluid (MSAF) may have meconium aspiration syndrome (MAS), which is a condition that causes respiratory distress due to the inhalation of meconium into the lungs.The priority action for the nurse is to evaluate the infant’s breathing and circulation and initiate resuscitation if needed.
Choice A is wrong because suctioning the infant’s mouth and nose with a bulb syringe is not recommended unless the infant has obvious meconium in the airway and is not vigorous.Suctioning may cause bradycardia, hypoxia, or airway trauma.
Choice C is wrong because drying and stimulating the infant with a warm towel is part of the initial steps of resuscitation, but it should be done after assessing the infant’s heart rate and respiratory effort.Drying and stimulating may also increase the risk of meconium aspiration if the infant gasps.
Choice D is wrong because clamping and cutting the umbilical cord is not a priority action for an infant with possible MAS.The cord should be clamped and cut after ensuring that the infant is stable and has adequate oxygenation.
Correct Answer is C
Explanation
Reticulocyte count 2%.
A reticulocyte count measures the percentage of immature red blood cells (RBCs) in the blood.A low reticulocyte count indicates that the bone marrow is not producing enough RBCs, which is a characteristic feature of anemia of prematurity (AOP).A normal reticulocyte count for preterm infants is 3-6%.
Choice A is wrong because hemoglobin 10 g/dL is within the normal range for preterm infants.
Hemoglobin is the protein in RBCs that carries oxygen.
A low hemoglobin level indicates anemia.
Choice B is wrong because hematocrit 30% is within the normal range for preterm infants.
Hematocrit is the percentage of blood volume that is occupied by RBCs.
A low hematocrit level indicates anemia.
Choice D is wrong because platelet count 150,000/mm3 is within the normal range for preterm infants.
Platelets are cell fragments that help with blood clotting.
A low platelet count indicates thrombocytopenia, which is a different condition from anemia.
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