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
A normal blood glucose level for a healthy term newborn is between 30 and 60 mg/dL.This range is lower than that of older children and adults, because newborns are adapting to life outside the womb and their glucose levels rise gradually after birth.
Choice A is wrong because 10 and 30 mg/dL is too low for a newborn and indicates hypoglycemia, which can cause symptoms such as jitteriness, poor feeding, lethargy, and cyanosis.
Choice C is wrong because 60 and 90 mg/dL is too high for a newborn and indicates hyperglycemia, which can cause symptoms such as dehydration, poor feeding, irritability, and seizures.
Choice D is wrong because 90 and 120 mg/dL is also too high for a newborn and indicates hyperglycemia, which can have the same consequences as choice C.
Correct Answer is B
Explanation
Encouraging frequent breastfeeding.
This is because breastfeeding provides glucose to the newborn baby, which can help prevent or treat hypoglycemia (low blood sugar).Hypoglycemia can cause problems such as shakiness, blue tint to the skin, and breathing and feeding problems.
Choice A is wrong because administering IV insulin would lower the blood sugar level even more, which could be dangerous for the baby.
Choice C is wrong because monitoring blood pressure is not directly related to hypoglycemia.
Blood pressure may be affected by other factors such as stress, infection, or dehydration.
Choice D is wrong because administering a hypertonic saline solution would increase the sodium level in the blood, which could cause dehydration and electrolyte imbalance.
A hypertonic saline solution is not a source of glucose for the baby.
Normal ranges for blood glucose levels in newborns are between 47 to 85 mg/dL.Hypoglycemia is defined as blood glucose below 47 mg/dL.
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