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

Answer and Explanation

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.

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Correct Answer is A

Explanation

This is because newborns with hypoglycemia need to receive adequate nutrition to raise their blood glucose levels and prevent neurologic damage.Early feeding also helps establish breast milk supply for nursing mothers.

Choice B is wrong because feeding the baby only when he cries may delay the intake of glucose and worsen the hypoglycemia.Newborns with hypoglycemia should be fed on demand or at least every 2 to 3 hours.

Choice C is wrong because feeding the baby every 6 hours is too infrequent and may cause prolonged hypoglycemia.Newborns with hypoglycemia should be fed on demand or at least every 2 to 3 hours.

Choice D is wrong because feeding the baby with glucose water may not provide enough calories and nutrients for growth and development.Newborns with hypoglycemia should be fed with breast milk or formula.Glucose water may be used as a temporary measure until breast milk or formula is available.

A. Monitor blood glucose levels every hour until stable. B. Administer glucagon subcutaneously as prescribed. C. Discontinue IV dextrose when blood glucose reaches 60 mg/dL. D. Feed breast milk or formula every four hours.

Correct Answer is A

Explanation

This is because hypoglycemia in newborns can cause seizures, brain damage, and developmental delays, and frequent monitoring can help detect and correct low blood glucose levels promptly.

Some additional information about the other choices are:

Choice B. Administer glucagon subcutaneously as prescribed.This is wrong because glucagon is used to treat hypoglycemia caused by hyperinsulinism, which is a rare condition in newborns.Most cases of hypoglycemia in term infants are due to transient factors such as delayed feeding, maternal diabetes, or perinatal stress.

Choice C. Discontinue IV dextrose when blood glucose reaches 60 mg/dL.This is wrong because 60 mg/dL is still below the normal range of blood glucose for newborns, which is 70 to 100 mg/dL.Discontinuing IV dextrose too early can cause rebound hypoglycemia and increase the risk of neurologic complications.

Choice D. Feed breast milk or formula every four hours.This is wrong because feeding every four hours may not be enough to maintain adequate blood glucose levels in newborns with hypoglycemia.Infants with hypoglycemia should be fed more frequently, such as every two to three hours, or on demand.Breast milk or formula can also be supplemented with IV dextrose if needed.

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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?

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Naxlex Comprehensive Predictor Exams

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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?