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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Feeding the baby every 2 hours helps to ensure frequent emptying of the breasts, which can help alleviate engorgement by reducing milk stasis and promoting milk production regulation.
Applying cold compresses before feeding may temporarily reduce discomfort but does not address the underlying cause of engorgement or promote milk removal.
Drinking herbal tea is not proven to effectively reduce breast engorgement, and it is important for the client to focus on frequent breastfeeding or pumping to alleviate engorgement.
Allowing the baby to drain one breast at each feeding may lead to uneven milk production and exacerbate engorgement. It is important for the client to offer both breasts at each feeding to ensure adequate milk removal from both breasts.
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.
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