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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Free Nursing Study Resources

Correct Answer is ["A","B","C","E"]

Explanation

Swaddling, pacifiers, gentle touch and music therapy are all non-pharmacological interventions that can help soothe a newborn during an assessment.

These methods can provide comfort, security, distraction and stimulation for the newborn.

Choice D is wrong because glucose water is a pharmacological intervention that can be used to reduce pain during procedures such as heel sticks or circumcision.Glucose water should not be given routinely to newborns as it can interfere with breastfeeding and cause electrolyte imbalances.

: PN maternal newborn practice B Flashcards | Quizlet: Maternal Newborn Alternate Item Format Quiz Flashcards | Quizlet: NCLEX-maternity and newborn Flashcards | Quizlet

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

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?

Correct Answer is ["A","B","C","E"]

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 is performing a head-to-toe assessment of a newborn. What finding should alert the nurse to a potential problem with the newborn’s fontanelles?

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:

A client asks the nurse about the purpose of the New Ballard Scale. How should the nurse respond?

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?

A nurse is teaching a class on Apgar scoring to nursing students. Which statement by a student indicates a need for further teaching

A nurse is caring for an infant who has a cephalohematoma on the left side of his skull. Which of the following interventions should the nurse implement?

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

A nurse is caring for a newborn who has an Apgar score of 8 at one minute after birth and an Apgar score of 10 at five minutes after birth. Which statement best describes this newborn’s condition?