A nurse is reviewing the transcutaneous bilirubin measurement of a newborn who is 48 hours old and has physiologic jaundice.
The measurement is 16 mg/dL.
Which of the following actions should the nurse take?
Initiate phototherapy immediately
Notify the provider to order a serum bilirubin test
Encourage the parent to feed the newborn more frequently
Reassure the parent that this is a normal finding
The Correct Answer is B
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
The baby is at risk for hemolytic jaundice if the mother has a different blood type that is incompatible with the baby’s blood type.This can cause the mother’s immune system to produce antibodies that attack the baby’s red blood cells, leading to hemolysis or excessive destruction of red blood cells.Hemolysis can cause bilirubin, a yellowish pigment, to accumulate in the baby’s blood, tissues, and fluids, causing jaundice.It can also cause anemia, a condition where the blood does not have enough healthy red blood cells.
Choice A is wrong because O positive is compatible with B negative.
O positive is the universal donor, meaning it can donate blood to any other blood type without causing a reaction.
Choice B is wrong because AB negative is compatible with B negative.
AB negative is the universal recipient, meaning it can receive blood from any other blood type without causing a reaction.
Choice D is wrong because A negative is incompatible with B negative.
A negative and B negative are different blood types that can cause a reaction if mixed together.
Correct Answer is C
Explanation
This is a sign of dehydration, which can be caused by phototherapy.Phototherapy increases insensible water loss through the skin and can lead to fluid and electrolyte imbalance in the newborn.The nurse should monitor the newborn’s hydration status, weight, urine output, and serum electrolytes and provide adequate fluid intake.
Choice A is wrong because conjunctivitis is not a common complication of phototherapy.It can be prevented by using eye shields or patches to protect the newborn’s eyes from the light source.
Choice B is wrong because bronze skin discoloration is a rare complication of phototherapy that occurs when the bilirubin level is very high and the skin pigment changes.It is not a priority finding and usually resolves after phototherapy is discontinued.
Choice D is wrong because maculopapular skin rash is a benign side effect of phototherapy that does not require intervention.It usually disappears within a few days after phototherapy is stopped.
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