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
A. Changing the perineal pad is a task that can be safely delegated to an assistive personnel (AP) as it involves basic hygiene care and does not require nursing judgment.
B. Observing an area of redness on the breast may require nursing assessment and judgment to determine if further intervention is needed.
C. Monitoring vital signs during admission of a client with gestational hypertension requires nursing assessment and judgment to detect any signs of worsening condition or complications.
D. Providing a sitz bath to a client with a fourth-degree laceration requires nursing assessment and judgment to ensure appropriate wound care and pain management.
Correct Answer is D
Explanation
A. Administering oxytocic medication may be necessary to stimulate uterine contractions and control bleeding, but palpating the client's uterine fundus is the priority to assess for uterine atony or excessive bleeding.
B. Increasing the client's fluid intake is important for hydration but does not address the immediate concern of potential postpartum hemorrhage.
C. Assisting the client on a bedpan to urinate is important for comfort and bladder emptying but does not address the priority of assessing and managing postpartum bleeding.
D. Palpating the client's uterine fundus is the priority nursing intervention to assess for uterine atony or excessive bleeding, which could indicate postpartum hemorrhage.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.