A nurse is caring for a client who had a post-term delivery and notes that the amniotic fluid was stained with meconium.

Which of the following actions should the nurse take first?

Suction the infant’s mouth and nose with a bulb syringe.

Assess the infant’s heart rate and respiratory effort.

Dry and stimulate the infant with a warm towel.

Clamp and cut the umbilical cord.

Answer and Explanation

The Correct Answer is B

This is because the infant born through meconium-stained amniotic fluid (MSAF) may have meconium aspiration syndrome (MAS), which is a condition that causes respiratory distress due to the inhalation of meconium into the lungs. The priority action for the nurse is to evaluate the infant’s breathing and circulation and initiate resuscitation if needed.

Choice A is wrong because suctioning the infant’s mouth and nose with a bulb syringe is not recommended unless the infant has obvious meconium in the airway and is not vigorous. Suctioning may cause bradycardia, hypoxia, or airway trauma.

Choice C is wrong because drying and stimulating the infant with a warm towel is part of the initial steps of resuscitation, but it should be done after assessing the infant’s heart rate and respiratory effort. Drying and stimulating may also increase the risk of meconium aspiration if the infant gasps.

Choice D is wrong because clamping and cutting the umbilical cord is not a priority action for an infant with possible MAS. The cord should be clamped and cut after ensuring that the infant is stable and has adequate oxygenation.

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Correct Answer is B

Explanation

This is because phototherapy can cause dehydration and increase insensible water loss, so covering the genitalia can prevent excessive fluid loss and maintain thermoregulation.

Some possible explanations for the other choices are:

• Choice A is wrong because monitoring skin temperature every hour is not enough to prevent hyperthermia or hypothermia during phototherapy.The skin temperature should be monitored continuously or at least every 15 minutes.

• Choice C is wrong because repositioning newborn every 4 hours is not frequent enough to prevent pressure ulcers, skin breakdown, or eye damage from the light source.The newborn should be repositioned at least every 2 hours.

• Choice D is wrong because encouraging parent-infant interaction as tolerated is not a specific intervention for phototherapy.

While parent-infant interaction is important for bonding and development, it should not interfere with the effectiveness of phototherapy.The newborn should be exposed to the light as much as possible, except for feeding and diaper changes.

Normal ranges for serum bilirubin levels vary depending on the age, gestational age, and risk factors of the newborn.Generally, the levels should be below 5 mg/dL for term infants and below 7 mg/dL for preterm infants by the fifth day of life.

A. Initiate phototherapy immediately B. Notify the provider to order a serum bilirubin test C. Encourage the parent to feed the newborn more frequently D. Reassure the parent that this is a normal finding

Correct Answer is B

Explanation

Transcutaneous bilirubin measurement is a useful screening tool for neonatal hyperbilirubinemia, but it has some limitations and sources of variability.Therefore, any bilirubin screening result obtained must be confirmed by a diagnostic method before treatment.

Choice A is wrong because initiating phototherapy without confirming the bilirubin level could expose the newborn to unnecessary treatment and potential adverse effects.

Choice C is wrong because increasing hydration by feeding more frequently may not be sufficient to lower the bilirubin level if it is too high or if there are other causes of jaundice.

Choice D is wrong because reassuring the parent that this is a normal finding could delay the diagnosis and treatment of severe neonatal hyperbilirubinemia, which can lead to serious complications such as kernicterus spectrum disorders.

Normal ranges for transcutaneous bilirubin measurement vary depending on the device used, the skin pigmentation, and the postnatal age of the newborn.However, a general guideline is that a measurement of 16 mg/dL at 48 hours of age is above the 95th percentile and warrants further investigation.

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A nurse is caring for a client who had a post-term delivery and notes that the amniotic fluid was stained with meconium. Which of the following actions should the nurse take first?

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Naxlex Comprehensive Predictor Exams

A nurse is planning care for a newborn who has hyperbilirubinemia and is receiving phototherapy. Which of the following interventions should the nurse include in the plan?

Correct Answer is B

Explanation

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Correct Answer is B

Explanation

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A nurse is caring for a client who had a post-term delivery and notes that the amniotic fluid was stained with meconium.

Which of the following actions should the nurse take first?