A nurse is evaluating the effectiveness of phototherapy for a post-term infant who has hyperbilirubinemia due to ABO incompatibility with the mother’s blood type O negative and infant’s blood type B positive.

Which of the following findings indicates that phototherapy is effective?

Loose, peeling skin without lanugo or vernix is a symptom of post-term infants who have intrauterine growth restriction (IUGR).Post-term infants are born after 42 weeks of gestation and may have reduced placental function, resulting in less nutrition and oxygen for the fetus.This can cause them to have low birth weight, decreased subcutaneous fat and muscle mass, and dry skin.

Choice A is wrong because a large head in proportion to body size is not a sign of IUGR.It may indicate a congenital anomaly or a chromosomal disorder.

Choice C is wrong because increased subcutaneous fat and muscle mass are not signs of IUGR.They are signs of normal fetal growth and development.

Choice D is wrong because hypertonia and hyperreflexia are not signs of IUGR.They may indicate a neurological problem or a perinatal asphyxia (lack of oxygen during birth).

Institute contact precautions.This is because the infant may havenecrotizing enterocolitis (NEC), which is the most common cause of bloody stool in preterm infants.

NEC is a serious condition that involves inflammation and necrosis of the intestinal wall and can lead to perforation, sepsis, and death.NEC is also a potential source of infection for other infants in the NICU, so contact precautions are necessary to prevent cross-contamination.

Choice A is wrong because obtaining a rectal temperature is not indicated for an infant with bloody stool.Rectal temperature can cause irritation and bleeding of the rectal mucosa and can also increase the risk of perforation if there is intestinal necrosis.

Choice C is wrong because decreasing the amount of the feeding is not enough to manage an infant with bloody stool.

The infant may need to have the feeding stopped completely and receive parenteral nutrition until the bowel heals.Decreasing the feeding may also compromise the infant’s growth and development.

Choice D is wrong because assessing for abdominal distention is not a nursing action but a nursing assessment.

Abdominal distention is a common sign of feeding intolerance and NEC, but it is not specific or sensitive enough to diagnose the condition.Other signs and symptoms of NEC include bile-stained or bloody gastric residuals, emesis, diarrhea, temperature instability, apnea, bradycardia, hypotension, and lethargy.