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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?

A.

Monitor blood glucose levels frequently.

B.

Begin phototherapy immediately.

C.

Initiate early feeding.

D.

Prepare for a blood transfusion.

Answer and Explanation

The Correct Answer is C

Choice A rationale

Monitoring blood glucose levels frequently is important for newborns, especially those at risk for hypoglycemia. However, it does not directly prevent jaundice. Jaundice is caused by elevated bilirubin levels, which are not directly related to blood glucose levels.

Choice B rationale

Beginning phototherapy immediately is a treatment for jaundice, not a preventive measure. Phototherapy is used to reduce high bilirubin levels in newborns who already have jaundice.

Choice C rationale

Initiating early feeding is an effective way to prevent jaundice in newborns. Early feeding helps promote regular bowel movements, which aids in the excretion of bilirubin from the body, thereby reducing the risk of jaundice.

Choice D rationale

Preparing for a blood transfusion is a treatment for severe jaundice, not a preventive measure. Blood transfusions are used in cases of extreme hyperbilirubinemia that do not respond to other treatments.


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Related Questions

Correct Answer is {"A":{"answers":"A"},"B":{"answers":"B"},"C":{"answers":"A"},"D":{"answers":"A"},"E":{"answers":"A"}}

Explanation

  1. “The glans penis will appear red and have a yellow crust as it heals. Do not remove this.”
    • Essential: This is a normal part of the healing process.
  2. “Ensure the diaper is really tight to keep the gauze attached to the penis.”
    • Contraindicated: The diaper should be loose to avoid pressure on the circumcision site.
  3. “Notify your pediatrician if your baby has not voided in 24 hours.”
    • Essential: This could indicate a problem that needs medical attention.
  4. “Coat the glans penis with petroleum jelly and cover with gauze.”
    • Essential: This helps prevent the diaper from sticking to the circumcision site and aids in healing.
  5. “Check for bleeding every 4 hours for the first 24 hours and notify your pediatrician if there is bleeding at the circumcision site.”
    • Essential: Monitoring for bleeding is crucial to ensure there are no complications.

Correct Answer is C

Explanation

Choice A rationale

Faint red marks on the plantar surface are more common in preterm infants and are not typically seen in post-term infants.

Choice B rationale

Copious vernix is usually seen in preterm infants. Post-term infants often have little to no vernix.

Choice C rationale

Dry, cracked skin is a common finding in post-term infants due to prolonged exposure to the amniotic fluid.

Choice D rationale

Scant scalp hair is more common in preterm infants. Post-term infants usually have more developed hair.

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