A nurse is caring for a newborn 4 hours after birth. Which of the following actions should the nurse include in the plan of care to prevent jaundice?

Prepare for an exchange blood transfusion.

Initiate early feeding.

Suction excess mucus with a bulb syringe.

Begin phototherapy.

Answer and Explanation

The Correct Answer is B

A.   Initiating early feeding helps promote the passage of meconium, which contains bilirubin, out of the newborn's body, reducing the risk of jaundice.

B.   Preparing for an exchange blood transfusion is not appropriate for preventing jaundice at this stage. Exchange transfusion is a treatment option for severe hyperbilirubinemia that has not
responded to other measures.
C.   Suctioning excess mucus with a bulb syringe is important for maintaining a patent airway in the newborn but does not directly prevent jaundice.
D.   Beginning phototherapy is a treatment for jaundice once it has occurred but is not a preventive measure.

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Correct Answer is B

Explanation

A. Applying ice packs to the breasts after feeding can help reduce swelling and discomfort associated with breast engorgement.
B. Applying hot packs to the breasts during feeding can increase blood flow and exacerbate engorgement. Heat can worsen inflammation and discomfort in the breasts.

C. Crushed cabbage leaves can be applied to the breasts between feedings to help reduce swelling and discomfort associated with engorgement.
D. Breastfeeding every 2 hours helps to ensure frequent emptying of the breasts, which can help alleviate engorgement.

A. Preeclampsia B. Disseminated intravascular coagulation C. Puerperal infection D. Anaphylactoid syndrome of pregnancy

Correct Answer is B

Explanation

A. Petechiae and bleeding around the IV access site are not typically associated with preeclampsia.
B. Disseminated intravascular coagulation (DIC) is a potential complication of abruptio placentae, characterized by widespread activation of the clotting cascade followed by consumption of clotting factors, leading to bleeding and microvascular thrombosis.

C. Puerperal infection is a risk following childbirth but is not specifically associated with petechiae and bleeding around the IV access site.
D. Anaphylactoid syndrome of pregnancy is a rare complication characterized by sudden hypotension, bronchospasm, and vascular collapse, which is not typically associated with petechiae and bleeding around the IV access site.

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A nurse is caring for a newborn 4 hours after birth. Which of the following actions should the nurse include in the plan of care to prevent jaundice?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is providing teaching about comfort measures for breast engorgement to a client who is postpartum and is breastfeeding. Which of the following statements by the client indicates a need for further teaching?

Correct Answer is B

Explanation

A nurse on the obstetric unit is caring for a client who experienced abruptio placentae. The nurse observes petechiae and bleeding around the IV access site. The nurse should recognize that this client is at risk for which of the following complications?

Correct Answer is B

Explanation

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