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 A
Explanation
Absent Moro reflex on the affected side indicates a possible injury to the brachial plexus, which is the nerve network that controls the movements and sensations of the shoulder, arm, hand and fingers.Shoulder dystocia can cause brachial plexus injuries when the baby’s shoulder gets stuck behind the mother’s pubic bone during delivery.
Choice B is wrong because flaccid paralysis of both lower extremities is not a common complication of shoulder dystocia.
It could be a sign of spinal cord injury or other neurological disorders.
Choice C is wrong because facial asymmetry when crying or smiling is a sign of facial nerve palsy, which can occur due to compression of the facial nerve during delivery.
It is not specific to shoulder dystocia.
Choice D is wrong because inability to suck or swallow is not a typical sign of shoulder dystocia.
It could be caused by other factors such as prematurity, neurological problems, or congenital anomalies.
Normal ranges for Moro reflex are present at birth and disappear by 4 to 6 months of age.
Normal ranges for facial nerve function are symmetrical movements of both sides of the face.
Normal ranges for sucking and swallowing are coordinated and effective feeding within the first hour after birth.
Correct Answer is B
Explanation
This is because the infant born through meconium-stained amniotic fluid (MSAF) may have meconium aspiration syndrome (MAS), which is a condition that causes respiratory distress due to the inhalation of meconium into the lungs.The priority action for the nurse is to evaluate the infant’s breathing and circulation and initiate resuscitation if needed.
Choice A is wrong because suctioning the infant’s mouth and nose with a bulb syringe is not recommended unless the infant has obvious meconium in the airway and is not vigorous.Suctioning may cause bradycardia, hypoxia, or airway trauma.
Choice C is wrong because drying and stimulating the infant with a warm towel is part of the initial steps of resuscitation, but it should be done after assessing the infant’s heart rate and respiratory effort.Drying and stimulating may also increase the risk of meconium aspiration if the infant gasps.
Choice D is wrong because clamping and cutting the umbilical cord is not a priority action for an infant with possible MAS.The cord should be clamped and cut after ensuring that the infant is stable and has adequate oxygenation.
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