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. Monitoring the newborn's blood pressure may be indicated in some situations but is not the priority in this case, as the symptoms described suggest hypoglycemia rather than hypertension.
B. Obtaining blood glucose by heel stick is the priority action. The symptoms of diaphoresis, jitteriness, and lethargy are indicative of hypoglycemia in newborns, and obtaining a blood glucose level will confirm the diagnosis and guide appropriate treatment.
C. Placing the newborn in a radiant warmer may help to prevent heat loss but does not address the underlying issue of hypoglycemia.
D. Initiating phototherapy is not indicated for the symptoms described, which suggest hypoglycemia rather than hyperbilirubinemia.

A. Use a suction catheter with low negative pressure. B. Suction the mouth with a bulb syringe. C. Turn the newborn on his side. D. Suction the nose with a bulb syringe.

Correct Answer is B

Explanation

A. Using a suction catheter is appropriate but may not be the quickest method for immediate airway clearance in this situation.
B. Suctioning the mouth with a bulb syringe is the priority action as it helps clear the airway of secretions and prevents aspiration, ensuring the newborn can breathe effectively.
C. Turning the newborn on his side can help with drainage but does not actively clear the airway, making it a less immediate priority.
D. Suctioning the nose is important, but the mouth should be cleared first to ensure a patent airway, making this option secondary.

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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

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