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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is F
Explanation
Choice A rationale
Abnormal stool patterns can be a sign of various issues in newborns, but they do not align with the vital signs presented. The vital signs suggest a more systemic issue rather than one isolated to digestive patterns.
Choice B rationale
While temperature regulation is critical in newborns, especially those who are preterm, the vital signs presented suggest a broader systemic issue. The symptoms do not align with isolated temperature dysregulation.
Choice C rationale
Feeding difficulties can be a sign of neonatal abstinence syndrome but are not directly reflected in the vital signs presented. Neonatal Abstinence Syndrome (NAS) encompasses a range of withdrawal symptoms due to exposure to drugs in utero, not just feeding issues.
Choice D rationale
While extremity issues can be present in various neonatal conditions, they do not align with the systemic symptoms shown in the vital signs. NAS impacts multiple body systems and would present more generalized symptoms.
Choice E rationale
Hypoglycemia can present with some of these vital signs, such as a rapid heart rate, but it does not explain all the symptoms like increased respiratory rate and temperature dysregulation. It is a condition that requires monitoring but is not the primary diagnosis suggested here.
Choice F rationale
Neonatal Abstinence Syndrome is consistent with the vital signs: elevated heart rate, increased respiratory rate, and lower temperature. NAS results from withdrawal from substances the newborn was exposed to in utero and affects multiple body systems, explaining the range of symptoms.
Correct Answer is D
Explanation
Choice A rationale
Placing the newborn in a radiant warmer is appropriate for managing hypothermia but does not directly address the signs of diaphoresis, jitteriness, and lethargy, which are indicative of hypoglycemia.
Choice B rationale
Monitoring the newborn's blood pressure is not the primary action needed for signs of hypoglycemia. The immediate need is to check blood glucose levels and address any hypoglycemia.
Choice C rationale
Initiating phototherapy is a treatment for hyperbilirubinemia (jaundice) and is not related to the signs of diaphoresis, jitteriness, and lethargy seen in hypoglycemia.
Choice D rationale
Obtaining blood glucose by heel stick is the correct action as the signs of diaphoresis, jitteriness, and lethargy are indicative of hypoglycemia. Checking blood glucose levels will help in diagnosing and managing the condition.
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