While conducting a daily assessment of a one-day-old newborn, the nurse notices a yellow tint on the baby’s forehead, sternum, and abdomen.
What should be the nurse’s next course of action?

Choice A rationale

Initiating phototherapy for the newborn is a treatment for jaundice, not a diagnostic step. It would be premature to start this treatment without confirming the diagnosis and assessing the severity of jaundice.

Choice B rationale

Reviewing the mother’s medical records for blood type and Rh factor can be useful in cases where Rh incompatibility is suspected. However, this would not be the immediate next step when observing a yellow tint on the baby’s skin.

Choice C rationale

Measuring bilirubin levels using transcutaneous bilirubinometry is the appropriate next step when jaundice is suspected in a newborn. This non-invasive test can quickly and accurately

measure bilirubin levels, helping to determine the severity of jaundice and guide treatment decisions.

Choice D rationale

Evaluating the results of the cord blood Coomb’s test can help identify cases of immune- mediated hemolytic disease of the newborn, a potential cause of neonatal jaundice. However, this would not typically be the first step taken when jaundice is observed.

Choice A rationale

In a situation where a client at 28 weeks gestation is in preterm labor and it is not expected that the fetus will survive after delivery, the nurse’s initial action should be to contact spiritual support services. This can provide much-needed emotional and spiritual support to the client during this difficult time.

Choice B rationale

While providing information about an autopsy might be necessary at some point, it should not be the initial action. The first response should be focused on providing emotional support.

Choice C rationale

Discussing neonatal resuscitation options might not be appropriate in this scenario, especially if it’s not expected that the fetus will survive. The initial focus should be on providing emotional support.

Choice D rationale

Contacting the organ donation organization is not the initial action to take in this situation. The first response should be providing emotional and spiritual support to the client.