A nurse is reviewing laboratory results for a newborn who was born to a mother who has type O positive blood and tested negative for hepatitis B surface antigen (HBsAg).

The newborn has type A positive blood and tested positive for Coombs antibody (anti-A).

Which of the following actions should the nurse take?

Administer hepatitis B immune globulin (HBIG) to the newborn within 12 hours of birth.

Monitor the newborn for signs of jaundice and anemia.

Obtain a blood sample from the newborn for blood typing and crossmatching.

Prepare the newborn for exchange transfusion with type O negative blood.

Answer and Explanation

The Correct Answer is B

Monitor the newborn for signs of jaundice and anemia.

This is because the newborn has a positive Coombs test, which means that there are antibodies against the newborn’s red blood cells (RBCs) in the blood.

These antibodies can cause hemolysis (destruction) of the RBCs, leading to jaundice (yellowing of the skin and eyes due to high bilirubin levels) and anemia (low RBC count and hemoglobin levels). The most likely cause of the positive Coombs test in this case is ABO incompatibility, which occurs when the mother has type O blood and the newborn has type A or B blood.

Choice A is wrong because administering hepatitis B immune globulin (HBIG) to the newborn within 12 hours of birth is indicated for newborns whose mothers are positive for hepatitis B surface antigen (HBsAg), which is not the case here.

Choice C is wrong because obtaining a blood sample from the newborn for blood typing and crossmatching is not necessary, as the newborn’s blood type is already known to be A positive.

Choice D is wrong because preparing the newborn for exchange transfusion with type O negative blood is a treatment option for severe cases of hemolytic disease of the newborn (HDN), which is not evident in this scenario. Exchange transfusion involves replacing the newborn’s blood with donor blood to remove antibodies and bilirubin.

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Correct Answer is B

Explanation

Flexion in different positions.The New Ballard Scale is a scale that estimates the gestational age of a newborn infant based on physical and neuromuscular characteristics.Flexion in different positions is one of the six neuromuscular signs that are assessed using the scale.The other neuromuscular signs are square window, arm recoil, popliteal angle, scarf sign, and heel to ear.

The other statements are wrong because:

Skin thickness and presence of lanugo are physical signs, not neuromuscular signs.They are also assessed using the New Ballard Scale, along with plantar surface, breast, eye/ear, and genitals.

Creases on the bottom of feet are part of the plantar surface assessment, which is a physical sign, not a neuromuscular sign.

Scrotum development is part of the genital assessment, which is a physical sign, not a neuromuscular sign.

The New Ballard Scale can be used up to 4 days after birth, but usually within the first 24 hours.The scale is accurate only within plus or minus 2 weeks.The total score determines the gestational maturity in weeks.

A. Place the newborn on the mother’s chest after delivery. B. Wrap the newborn in a blanket and hand to the father. C. Place the newborn in an isolette next to the mother’s bed. D. Dress the newborn in a gown and hat before giving to the mother.

Correct Answer is A

Explanation

Place the newborn on the mother’s chest after delivery.This is because skin-to-skin contact between mother and baby promotes bonding and attachment, which are essential for the baby’s emotional and psychological development.Skin-to-skin contact also helps regulate the baby’s body temperature, heart rate, breathing and blood sugar levels.

Choice B is wrong because wrapping the newborn in a blanket reduces the skin-to-skin contact and may interfere with the bonding process.The father can also bond with the baby by holding him or her against his own skin.

Choice C is wrong because placing the newborn in an isolette separates the baby from the mother and prevents close interaction and communication.The baby may feel insecure and isolated in an isolette.

Choice D is wrong because dressing the newborn in a gown and hat also reduces the skin-to-skin contact and may delay the initiation of breastfeeding.The baby may also lose more heat through clothing than through direct contact with the mother’s body.

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Naxlex Comprehensive Predictor Exams

A nurse is performing the physical maturity test on a newborn using the New Ballard Scale. What characteristic would the nurse assess?

Correct Answer is B

Explanation

A nurse is supporting bonding and attachment between parents and their newborn. What intervention should the nurse implement to promote skin-to-skin contact?

Correct Answer is A

Explanation

A nurse observes that an infant has an elongated head shape due to molding during delivery. The nurse explains to the parents that this condition is called:

Select all that apply. A nurse is providing comfort measures to a newborn during an assessment. What non-pharmacological interventions can the nurse use to soothe the newborn?

A nurse palpates an infant’s anterior fontanelle and notes that it feels soft and flat when lying down, but slightly elevated when sitting up or crying. What should be included in documentation?

A nurse is caring for a newborn who has hyperbilirubinemia and is receiving phototherapy. Which of the following interventions should the nurse implement?

A nurse is assessing an older adult client’s mouth. The nurse should identify that which of the following is an expected variation for this client?

A nurse is preparing to administer erythromycin ointment to a newborn’s eyes as prophylaxis for gonorrhea and chlamydia infections. Which of the following actions should the nurse take?