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 A

Explanation

A. Breast milk typically "comes in" or becomes more abundant between 3 to 5 days after birth as colostrum transitions to mature milk.
B. Within 2 days is too soon for most women to experience their milk "coming in."

C. 6 to 8 days is later than the typical timeframe for milk production to increase significantly.

D. About 10 days is longer than the average time for breast milk to "come in" for most postpartum women.

A. A newborn who is 24-hr post-delivery and has not passed meconium B. A newborn who is 12 hr post-delivery and has a temperature of 37.5° C (99.5° F) C. A newborn who is 18 hr post-delivery and has acrocyanosis D. A newborn who is 24 hr post-delivery and has not voided

Correct Answer is D

Explanation

A. Not passing meconium within 24 hours may indicate meconium ileus or another bowel obstruction, but it's not an immediate concern.

B. A temperature of 37.5°C (99.5°F) is within the normal range for a newborn and does not require immediate intervention.
C. Acrocyanosis, blueness of the extremities, is a common finding in newborns and does not require immediate intervention.
D. A newborn who is 24 hours post-delivery and has not voided requires immediate intervention as it may indicate a urinary tract obstruction or another issue that needs prompt assessment and management.

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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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Correct Answer is D

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