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?

Monitor blood glucose levels frequently.

Begin phototherapy immediately.

Initiate early feeding.

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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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.

A. Hepatitis B vaccine only, administered within 1 hour of birth. B. Hepatitis B vaccine and Hepatitis B immunoglobulin administered within 12 hours of delivery. C. Hepatitis B immunoglobulin (HBIG) only, administered within 12 hours of birth. D. Hepatitis B immunoglobulin (HBIG) within 12 hours, followed by hepatitis B vaccine monthly for 12 months.

Correct Answer is B

Explanation

Choice A rationale

Administering only the Hepatitis B vaccine within 1 hour of birth is not sufficient for a newborn born to a Hepatitis B positive mother. The newborn also needs Hepatitis B immunoglobulin (HBIG) to provide immediate passive immunity.

Choice B rationale

Administering both the Hepatitis B vaccine and Hepatitis B immunoglobulin (HBIG) within 12 hours of delivery is the recommended practice for newborns born to Hepatitis B positive mothers. This provides both active and passive immunity.

Choice C rationale

Administering only Hepatitis B immunoglobulin (HBIG) within 12 hours of birth is not sufficient. The newborn also needs the Hepatitis B vaccine to develop long-term immunity.

Choice D rationale

Administering Hepatitis B immunoglobulin (HBIG) within 12 hours, followed by monthly Hepatitis B vaccines for 12 months, is not the standard practice. The newborn should receive the Hepatitis B vaccine series according to the recommended schedule. .

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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?

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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?