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?

Initiate phototherapy for the newborn.

Review the mother’s medical records for blood type and Rh factor.

Measure bilirubin levels using transcutaneous bilirubinometry.

Evaluate the results of the cord blood Coomb’s test.

Answer and Explanation

The Correct Answer is C

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.

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Correct Answer is B

Explanation

Choice B rationale

When preparing to administer magnesium sulfate to a laboring client with elevated blood pressure, ensuring that calcium gluconate is immediately available is of the highest priority. Calcium gluconate is the antidote for magnesium sulfate toxicity, and having it readily available is crucial in case of an overdose.

Choice A rationale

While assessing deep tendon reflexes (DTRs) every 4 hours is an important part of monitoring a client receiving magnesium sulfate, it is not the most immediate priority when preparing to administer the medication.

Choice C rationale

Inserting a Foley catheter with a urimeter to monitor hourly output is an important part of the overall management of a client receiving magnesium sulfate. However, it is not the most immediate priority when preparing to administer the medication.

Choice D rationale

Providing a quiet environment with subdued lighting can contribute to the comfort of a laboring client. However, it is not the most immediate priority when preparing to administer magnesium sulfate.

A. Assess the client’s perineal area for signs of a perineal hematoma. B. Assess the client’s temperature, pulse, and respirations every 4 hours. C. Notify the healthcare provider, since this finding is indicative of infection. D. Check the differential, since the WBC is normal for this client.

Correct Answer is D

Explanation

Choice A rationale

While a perineal hematoma can lead to increased WBC count, there is no indication of such a complication, making this assessment less immediate.

Choice B rationale

Assessing vital signs is an important part of routine postpartum care. Still, a white blood cell count of 15,000/mm is within a normal range for a woman within the first 24-48 hours after delivery and is not necessarily indicative of infection.

Choice C rationale

While an elevated WBC can indicate infection, a postpartum woman's white blood cell count can be normally elevated up to 20,000/mm due to the stress of labor and delivery. Checking a differential will provide a more accurate breakdown of different types of white blood cells for a more precise assessment.

Choice D rationale

A normal WBC in a postpartum client ranges from (12,000- 20, 000/mm. Checking the white blood cell differential helps determine the specific types of WBCs present and gives more information as to whether the elevation is the body's normal response to childbirth or a sign of infection.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is preparing to administer magnesium sulfate to a laboring client whose blood pressure has risen from 110/60 mmHg to 140/90 mmHg.Which nursing protocol is of the highest priority?

Correct Answer is B

Explanation

One day after vaginal delivery of a full-term baby, a postpartum client’s white blood cell count is 15,000/mm (15 x 109/L). What action should the nurse take first?

Correct Answer is D

Explanation

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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?