A nurse is preparing to administer an exchange transfusion to a newborn who has severe hyperbilirubinemia due to Rh incompatibility.
Which of the following actions should the nurse take first?
Obtain informed consent from the parent.
Check the newborn’s blood type and crossmatch.
Insert two umbilical catheters for blood withdrawal and infusion.
Monitor the newborn’s vital signs and oxygen saturation.
The Correct Answer is A
Exchange transfusion (ET) is a procedure that involves removing the infant’s blood and replacing it with compatible donor blood to reduce the level of bilirubin and/or antibody-coated red blood cells. It is a high-risk intervention that can cause serious complications such as vascular accidents, cardiovascular compromise, and electrolyte and hematologic derangement.
Therefore, it is essential to obtain informed consent from the parent before performing ET.
Choice B is wrong because checking the newborn’s blood type and crossmatch is not the first action the nurse should take.
Although it is important to ensure compatibility between the donor and recipient blood, it is not as urgent as obtaining informed consent.
Choice C is wrong because inserting two umbilical catheters for blood withdrawal and infusion is not the first action the nurse should take.
Although it is necessary to establish vascular access for ET, it is not as crucial as obtaining informed consent.
Choice D is wrong because monitoring the newborn’s vital signs and oxygen saturation is not the first action the nurse should take.
Although it is vital to assess the newborn’s condition before, during, and after ET, it is not as imperative as obtaining informed consent.
Normal ranges for bilirubin levels vary depending on the gestational age and postnatal age of the newborn. The American Academy of Pediatrics (AAP) has published nomograms for initiating phototherapy and ET based on these factors. According to the AAP, ET should be considered when the bilirubin level exceeds 25 mg/dL (428 μmol/L) in term infants or 20 mg/dL (342 μmol/L) in preterm infants with risk factors for neurotoxicity.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Bronchospasm.
Bronchospasm is a constriction of the airways that causes wheezing and trouble breathing.It is one of the symptoms of anaphylaxis, a severe allergic reaction that can occur within minutes of exposure to something you’re allergic to, such as a bee sting.
Choice A is wrong because bradycardia is a slow heart rate, not a fast one.Anaphylaxis causes a weak and rapid pulse due to low blood pressure.
Choice B is wrong because hypertension is high blood pressure, not low.Anaphylaxis causes blood pressure to drop suddenly and can lead to shock.
Choice D is wrong because warm, dry skin is not a sign of anaphylaxis.Anaphylaxis causes skin reactions such as hives, itching, flushed or pale skin.
Correct Answer is C
Explanation
Jitteriness and poor feeding are common signs of hypoglycemia in a newborn.
Hypoglycemia is when the level of sugar (glucose) in the blood is too low.
Glucose is the main source of fuel for the brain and the body.In a newborn baby, low blood sugar can cause problems such as shakiness, blue tint to the skin, and breathing and feeding problems.
Choice A is wrong because hypertension and bradycardia are not typical symptoms of hypoglycemia in a newborn.
They may indicate other conditions such as heart problems or infection.
Choice B is wrong because diarrhea and vomiting are not specific symptoms of hypoglycemia in a newborn.
They may be caused by many other factors such as infection, food intolerance, or gastroesophageal reflux.
Choice D is wrong because hyperactivity and irritability are not usual symptoms of hypoglycemia in a newborn.
They may be signs of other conditions such as pain, hunger, or overstimulation.
Normal ranges for blood glucose levels in newborns vary depending on the age, gestational age, and feeding status of the baby.Most doctors consider blood glucose that is below 47 milligrams per deciliter (mg/dl) to be the definition of hypoglycemia in newborns.
However, some babies may need higher levels to prevent brain injury.
A doctor will monitor the blood glucose levels of a newborn at risk for hypoglycemia and treat accordingly.
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