The nurse evaluates a 10-hour-old newborn who is B-negative blood type and whose mother is O+. The nurse assesses the newborn to have noticeable yellow discoloration of the skin.
The nurse reports this as pathologic jaundice and understands that which finding is most helpful in reducing jaundice in the infant?
Frequent bowel movements.
A stable temperature of 98.0°F axillary.
6-8 voids in a 24-hour period.
A heel stick of 60.
The Correct Answer is A
Choice A rationale
Frequent bowel movements help excrete bilirubin, which reduces jaundice. Newborns pass meconium and transitional stools frequently, aiding in bilirubin clearance.
Choice B rationale
A stable temperature is important for overall health, but it does not specifically impact bilirubin levels or jaundice.
Choice C rationale
A newborn should have 6-8 voids per day indicating good hydration, but it is not directly related to reducing jaundice.
Choice D rationale
A heel stick with a glucose level of 60 may indicate glucose monitoring but is not related to jaundice management.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A rationale
Simply reassuring the parents does not provide them with actions they can take to support their baby's care. While reassurance is important, it must be paired with practical advice that empowers the parents and involves them in the baby's care.
Choice B rationale
Discharge teaching on SIDS prevention is essential but is premature for parents with a 24-week preemie in NICU. The immediate focus should be on supporting them with current care practices and preparing them for future involvement in their baby's daily needs.
Choice C rationale
Discussing diapering, skin, and umbilical cord care is important, but it is not the immediate priority in the NICU context. Parents need guidance on how to support their baby’s current complex care needs rather than routine newborn care at this stage.
Choice D rationale
Emphasizing the importance of pumping breast milk is the most appropriate action. Breast milk is crucial for the baby's nutrition and immune support once enteral feedings begin. This action empowers the parents to actively contribute to their baby's care and prepares for future needs. .
Correct Answer is C
Explanation
Choice A rationale
The Moro reflex is a startle response in newborns and does not assist in promoting latching during breastfeeding.
Choice B rationale
The stepping reflex, also known as the walking reflex, involves a newborn making stepping movements when held upright and does not contribute to latching during breastfeeding.
Choice C rationale
The rooting reflex causes a newborn to turn their head toward a touch on their cheek and begin sucking movements, which is crucial for promoting latching during breastfeeding.
Choice D rationale
The Babinski reflex involves the toes fanning out when the sole of the foot is stroked and is unrelated to latching during breastfeeding. .
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