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.
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Related Questions
Correct Answer is B
Explanation
This is because phototherapy can cause dehydration and increase insensible water loss, so covering the genitalia can prevent excessive fluid loss and maintain thermoregulation.
Some possible explanations for the other choices are:
• Choice A is wrong because monitoring skin temperature every hour is not enough to prevent hyperthermia or hypothermia during phototherapy.The skin temperature should be monitored continuously or at least every 15 minutes.
• Choice C is wrong because repositioning newborn every 4 hours is not frequent enough to prevent pressure ulcers, skin breakdown, or eye damage from the light source.The newborn should be repositioned at least every 2 hours.
• Choice D is wrong because encouraging parent-infant interaction as tolerated is not a specific intervention for phototherapy.
While parent-infant interaction is important for bonding and development, it should not interfere with the effectiveness of phototherapy.The newborn should be exposed to the light as much as possible, except for feeding and diaper changes.
Normal ranges for serum bilirubin levels vary depending on the age, gestational age, and risk factors of the newborn.Generally, the levels should be below 5 mg/dL for term infants and below 7 mg/dL for preterm infants by the fifth day of life.
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.
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