Which statement describing physiologic jaundice is incorrect?
Breastfed babies have a lower incidence of jaundice.
Neonatal jaundice is common, but kernicterus is rare.
Because jaundice may not appear before discharge, parents need instruction on how to assess it and when to call for medical help.
The appearance of jaundice during the first 24 hours or beyond day 7 indicates a pathologic process.
The Correct Answer is A
Choice A rationale
The statement is incorrect because breastfed babies actually have a higher incidence of physiologic jaundice, often peaking at higher serum bilirubin levels (e.g., up to 15 mg/dL) and lasting longer (up to several weeks) compared to formula-fed infants. This phenomenon, termed "breast-milk jaundice" or "breastfeeding-associated jaundice," is likely due to factors in the milk or less frequent stooling, but is usually benign. The normal total serum bilirubin range is typically <5 mg/dL in the first 24 hours.
Choice B rationale
Physiologic neonatal jaundice, caused by immature hepatic function and increased red blood cell breakdown, is exceedingly common, affecting up to 60% of full-term newborns. Kernicterus, which is chronic and permanent neurological damage from bilirubin deposition in the basal ganglia and brainstem, is extremely rare. Early detection and treatment prevent bilirubin levels from reaching the neurotoxic threshold (typically >25 mg/dL).
Choice C rationale
Because physiologic jaundice typically peaks between 72 and 96 hours of age, after most healthy newborns are discharged, parents must be educated on how to visually assess for the cephalocaudal progression of yellowing skin and sclera. They need specific instructions on when to contact a healthcare provider for signs of excessive jaundice or poor feeding, which is crucial for preventing severe hyperbilirubinemia.
Choice D rationale
Jaundice appearing within the first 24 hours of life is almost always pathologic, commonly due to hemolytic disease (e.g., Rh or ABO incompatibility), which causes rapid bilirubin rise. Jaundice persisting past day 7 in a term infant or day 14 in a preterm infant also strongly suggests a pathologic process requiring further investigation, such as infection or metabolic disorders.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale
Magnesium sulfate is a central nervous system depressant and a smooth muscle relaxant. While it can cause fluid shifts, it is not primarily known for causing urinary frequency. In fact, if therapeutic levels become too high, it can lead to decreased urinary output (oliguria) by inhibiting the renal system, thereby increasing the risk of magnesium toxicity. Urinary output is a key assessment for magnesium toxicity.
Choice B rationale
Magnesium sulfate acts as a peripheral vasodilator, causing relaxation of vascular smooth muscle, which leads to a decrease in systemic vascular resistance. This peripheral vasodilation causes a sensation of warmth and a visible flushing of the skin, particularly in the face and neck, due to increased cutaneous blood flow. This effect is a very common, expected side effect upon initiation of the infusion.
Choice C rationale
While not a primary, expected side effect, headaches are a generalized symptom that could potentially be associated with changes in blood pressure or fluid dynamics, but the prominent side effect from magnesium's vasodilation is the flush. Hypotension, stemming from vasodilation, is a more directly related cardiovascular effect than headache, which is not universally reported.
Choice D rationale
Nausea and vomiting are possible side effects of magnesium sulfate, linked to its general smooth muscle relaxing effects, potentially affecting gastrointestinal motility. However, the most immediate and common patient-reported side effect upon infusion is the warm flush due to its potent peripheral vasodilatory action, making the flush the most pertinent information to provide first.
Correct Answer is B
Explanation
Choice A rationale
At 48 hours (2 days) postpartum, the normal physiological process of uterine involution should have already progressed beyond the umbilicus. Immediately after birth, the fundus is firm, midline, and typically at the umbilicus (or 1-2 fingerbreadths below). A fundus remaining at the umbilicus at 48 hours could suggest subinvolution or retained products.
Choice B rationale
Uterine involution, the process of the uterus returning to its non-pregnant state, typically involves a descent of approximately 1 cm (one fingerbreadth) every 24 hours. Therefore, after 48 hours (2 days), the fundus is expected to be about two fingerbreadths (or ≈ 2 cm) below the level of the umbilicus in a healthy postpartum woman experiencing normal involution.
Choice C rationale
A fundus located two fingerbreadths above the umbilicus at 48 hours postpartum is an abnormal finding. This suggests that the uterus is larger than expected, potentially due to uterine atony (a lack of muscle tone) or the presence of a full bladder, which displaces the uterus superiorly and laterally, predisposing the client to postpartum hemorrhage.
Choice D rationale
While the fundus does descend, four fingerbreadths (about 4 cm) below the umbilicus is the typical location expected around the fourth day postpartum, not the second. This measurement indicates the expected daily rate of involution; therefore, a descent this low at 48 hours would be faster than the expected physiological rate of descent.
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