A nurse is caring for a newborn 4 hr after birth. Which of the following actions should the nurse include in the plan of care to prevent jaundice?

Initiate early feeding.

Suction excess mucus with a bulb syringe.

Prepare for an exchange blood transfusion.

Begin phototherapy.

Answer and Explanation

The Correct Answer is A

A) Initiate early feeding:

Early and frequent breastfeeding or formula feeding helps stimulate bowel movements, which aid in the elimination of bilirubin from the body. Breast milk also contains substances that promote bilirubin excretion, making early feeding an effective preventive measure against neonatal jaundice.

B) Suction excess mucus with a bulb syringe:

While clearing excess mucus can facilitate breathing and feeding, it does not directly prevent jaundice.

C) Prepare for an exchange blood transfusion:

Exchange transfusion is a treatment option for severe jaundice that has not responded to other measures. It is not a preventive measure.

D) Begin phototherapy:

Phototherapy is a treatment for jaundice after it has occurred, not a preventive measure. It involves exposing the newborn's skin to specific wavelengths of light to break down excess bilirubin.

Nursing Test Bank

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

Correct Answer is A

Explanation

A) Client is Rh negative and the newborn is Rh positive:

This is the correct response. Rho (D) Immunoglobulin, also known as RhoGAM, is administered to Rh-negative mothers who have given birth to Rh-positive infants. This medication helps prevent the mother's immune system from producing antibodies against Rh-positive blood cells, which could lead to hemolytic disease of the newborn in subsequent pregnancies. Administering RhoGAM in this scenario helps prevent sensitization of the mother's immune system to Rh-positive blood cells.

B) Client is Rh positive and the newborn is Rh negative:

Administering RhoGAM to an Rh-positive mother with an Rh-negative newborn would not be necessary because there is no risk of Rh incompatibility in this situation.

C) Client is Rh positive and the newborn is Rh positive:

Administering RhoGAM to an Rh-positive mother with an Rh-positive newborn would not be necessary because the mother and newborn share the same Rh factor, so there is no risk of Rh incompatibility.

D) Client is Rh negative and the newborn is Rh negative:

Administering RhoGAM to an Rh-negative mother with an Rh-negative newborn would not be necessary because there is no risk of Rh incompatibility in this situation.

A. Educate parents on blood glucose monitoring. B. Obtain a blood sample for blood type. C. Administer thyroid hormone replacement. D. Initiate a controlled low-protein diet.

Correct Answer is D

Explanation

A) Educate parents on blood glucose monitoring:

Blood glucose monitoring is not directly related to the care of a newborn with phenylketonuria (PKU). PKU is a metabolic disorder that affects the body's ability to process phenylalanine, an amino acid found in protein. Therefore, educating parents on blood glucose monitoring is not relevant to the management of PKU.

B) Obtain a blood sample for blood type:

Obtaining a blood sample for blood type is a routine procedure performed shortly after birth to determine the newborn's blood type and Rh factor. While this is an important aspect of newborn care, it is not specific to the management of PKU.

C) Administer thyroid hormone replacement:

Administering thyroid hormone replacement is not indicated for a newborn with PKU. PKU is a metabolic disorder caused by a deficiency of the enzyme phenylalanine hydroxylase, which leads to the accumulation of phenylalanine in the body. Thyroid hormone replacement is used to treat hypothyroidism, a condition involving an underactive thyroid gland, and is not related to PKU management.

D) Initiate a controlled low-protein diet:

Initiating a controlled low-protein diet is a crucial aspect of managing PKU. Since PKU is characterized by the inability to metabolize phenylalanine properly, dietary management aims to limit phenylalanine intake by implementing a low-protein diet. This diet helps prevent the accumulation of phenylalanine in the body, reducing the risk of neurological damage and other complications associated with PKU. Therefore, including this action in the plan of care is essential for effectively managing PKU in the newborn.

View Question and Answer

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

A nurse is caring for a newborn 4 hr 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

A nurse is caring for a client who is postpartum and has a prescription for Rho (D) Immunoglobulin. The nurse should verify which of the following prior to administration?

Correct Answer is A

Explanation

A nurse is planning care for a newborn who has a new diagnosis of phenylketonuria (PKU). Which of the following actions should be included in the plan of care?

Correct Answer is D

Explanation

A nurse is caring a client who is 3 days postpartum and is attempting to breastfeed. Which of the following findings indicate mastitis?

A nurse is performing a physical examination of a client who is 1 day postpartum. Which of the following findings requires immediate intervention?

A nurse is preparing to administer vitamin K by IM injection to a newborn. The nurse should administer the medication into which of the following muscles?

A nurse is caring for a client who is postpartum and received methylergonovine. Which of the following findings indicates that the medication was effective?

A nurse is caring for a client who just delivered a newborn. Following the delivery, which nursing action should be done first to care for the newborn?

A nurse on a postpartum unit is giving discharge instructions to a client whose newborn had a circumcision with the Plastibell technique. Which of the following client statements indicates understanding of circumcision care? (Select all that apply.)

A nurse is assisting with the care of a newborn immediately following birth. Which of the following medications should the nurse anticipate administering? (Select all that apply.)

A nurse is caring for a client who is 1 hr postpartum and observes a large amount of lochia rubra and several small clots on the client's perineal pad. The fundus is midline and firm at the umbilicus. Which of the following actions should the nurse take?