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 B
Explanation
Transcutaneous bilirubin measurement is a useful screening tool for neonatal hyperbilirubinemia, but it has some limitations and sources of variability.Therefore, any bilirubin screening result obtained must be confirmed by a diagnostic method before treatment.
Choice A is wrong because initiating phototherapy without confirming the bilirubin level could expose the newborn to unnecessary treatment and potential adverse effects.
Choice C is wrong because increasing hydration by feeding more frequently may not be sufficient to lower the bilirubin level if it is too high or if there are other causes of jaundice.
Choice D is wrong because reassuring the parent that this is a normal finding could delay the diagnosis and treatment of severe neonatal hyperbilirubinemia, which can lead to serious complications such as kernicterus spectrum disorders.
Normal ranges for transcutaneous bilirubin measurement vary depending on the device used, the skin pigmentation, and the postnatal age of the newborn.However, a general guideline is that a measurement of 16 mg/dL at 48 hours of age is above the 95th percentile and warrants further investigation.
Correct Answer is A
Explanation
“We need to monitor your kidney function because SLE can cause glomerulonephritis.” Glomerulonephritis is kidney inflammation caused by SLE that can damage the filtering units of the kidneys called glomeruli.SLE is an autoimmune disease that can affect various organs and tissues, including the kidneys.About half of the people with lupus experience kidney involvement, which can lead to kidney failure if not treated.
Therefore, it is important to monitor the kidney function of people with SLE.
Choice B is wrong because SLE does not cause hepatic necrosis, which is the death of liver cells.SLE can cause inflammation of the liver, but this is less common and less severe than kidney involvement.
Choice C is wrong because SLE does not cause hypothyroidism, which is a condition where the thyroid gland does not produce enough thyroid hormones.
SLE can affect the thyroid gland, but this is rare and usually does not affect the thyroid function.
Choice D is wrong because SLE does not cause diabetes mellitus, which is a condition where the body cannot regulate blood sugar levels.
SLE can cause inflammation of the pancreas, but this is uncommon and usually does not affect the insulin production.
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