1. A nurse is caring for a newborn immediately following birth.

Exhibit 1

Medical History

Vacuum-assisted vaginal birth

Maternal history of positive group B streptococcus 8-hemolytic Mother received two doses of ampicillin IV bolus during labor

Exhibit 2

Vital Signs

Apgar:

Heart rate 96/min

Weak cry

Muscle tone: some flexion

Reflex: grimace

Color: acrocyanosis

Axillary temperature 36.9° C (98.5° F)

Exhibit 3

Medications

Erythromycin ophthalmic ointment once 1 to 2 hr after birth Hepatitis B vaccine 10 mcg/0.5 mL IM once within 24 hr after birth

Phytonadione 1 mg IM once 1 to 2 hr after birth

Exhibit 4

Laboratory Findings

WBC count 15,000mm (9,000 to 30,000/mm)

Hgb 19 g/dl (15 to 24 g/dL)

HCt 57% (44% to 70%)

Blood glucose 44 mg/dl (40 to 60 mg/dL)

The nurse is assessing the newborn 24 hr later. How should the nurse interpret the findings?

For each finding, click to specify whether the finding is unrelated to the diagnosis, an indication that the client's condition is improving, or indication that the client's condition is worsening

A. Turn the newborn every 4 hr:

Turning the newborn every 4 hours is a routine nursing intervention to prevent pressure ulcers in infants. However, it is not specifically related to phototherapy treatment. Turning the newborn should be done as per routine care, but it is not a direct action related to phototherapy.

B. Close the newborn's eyes before applying eyepatches:

It is important to protect the newborn's eyes from the bright light used in phototherapy. Therefore, closing the newborn's eyes before applying eyepatches or covering them with eye protection is necessary during phototherapy to prevent eye damage.

C. Provide the newborn with 15 mL glucose water after each feeding:

Providing glucose water after each feeding is not a standard practice for newborns undergoing phototherapy. Instead, the primary focus during phototherapy is on feeding the baby adequately to promote hydration and excretion of bilirubin through stool and urine. Glucose water is not routinely recommended unless specifically ordered by the healthcare provider for a medical indication.

D. Apply hydrating lotion to the newborn's skin prior to treatment:

Hydrating lotion should not be applied to the newborn's skin prior to phototherapy. Lotions, oils, or creams can interfere with the effectiveness of phototherapy by creating a barrier that blocks the light from reaching the baby's skin. Therefore, it is essential to keep the baby's skin clean and free from lotions or ointments during phototherapy.

A.Dry mucous membranes may indicate dehydration. The newborn is breastfeeding only 3–4 times per day, which is lower than the recommended 8–12 feedings per day for adequate hydration and nutrition.

B.Yellow sclera suggests jaundice, which could indicate neonatal hyperbilirubinemia. Since the newborn is Coombs-positive, there is an increased risk of hemolytic disease of the newborn (HDN) due to blood incompatibility, making bilirubin monitoring essential.

D.The newborn has voided only once in 36 hours, which may indicate dehydration or inadequate fluid intake. Additionally, the absence of a meconium stool may suggest intestinal obstruction, delayed passage, or meconium plug syndrome, requiring further evaluation.

E.A positive Coombs test means that maternal antibodies have attacked the newborn’s red blood cells, increasing the risk of hemolytic anemia and jaundice. This finding correlates with the yellow sclera, necessitating further bilirubin monitoring.

Incorrect answers:

C.Caput succedaneum is benign and self-resolving. It is a soft tissue swelling from birth trauma and does not require intervention.

F.A respiratory rate of 44 breaths/min is within the normal range (30–60 breaths/min) for a newborn and does not indicate distress.