A nurse is caring for an infant who has a high Bilirubin level and is receiving phototherapy.
Which of the following is the priority finding in the newborn?
Conjunctivitis
Bronze discoloration of the skin
Sunken fontanelles
Maculopapular skin rash.
The Correct Answer is C
This is a sign of dehydration, which can be caused by phototherapy. Phototherapy increases insensible water loss through the skin and can lead to fluid and electrolyte imbalance in the newborn. The nurse should monitor the newborn’s hydration status, weight, urine output, and serum electrolytes and provide adequate fluid intake.
Choice A is wrong because conjunctivitis is not a common complication of phototherapy. It can be prevented by using eye shields or patches to protect the newborn’s eyes from the light source.
Choice B is wrong because bronze skin discoloration is a rare complication of phototherapy that occurs when the bilirubin level is very high and the skin pigment changes. It is not a priority finding and usually resolves after phototherapy is discontinued.
Choice D is wrong because maculopapular skin rash is a benign side effect of phototherapy that does not require intervention. It usually disappears within a few days after phototherapy is stopped.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
This is because hypoglycemia in newborns can cause seizures, brain damage, and developmental delays, and frequent monitoring can help detect and correct low blood glucose levels promptly.
Some additional information about the other choices are:
Choice B. Administer glucagon subcutaneously as prescribed.This is wrong because glucagon is used to treat hypoglycemia caused by hyperinsulinism, which is a rare condition in newborns.Most cases of hypoglycemia in term infants are due to transient factors such as delayed feeding, maternal diabetes, or perinatal stress.
Choice C. Discontinue IV dextrose when blood glucose reaches 60 mg/dL.This is wrong because 60 mg/dL is still below the normal range of blood glucose for newborns, which is 70 to 100 mg/dL.Discontinuing IV dextrose too early can cause rebound hypoglycemia and increase the risk of neurologic complications.
Choice D. Feed breast milk or formula every four hours.This is wrong because feeding every four hours may not be enough to maintain adequate blood glucose levels in newborns with hypoglycemia.Infants with hypoglycemia should be fed more frequently, such as every two to three hours, or on demand.Breast milk or formula can also be supplemented with IV dextrose if needed.
Correct Answer is B
Explanation
Institute contact precautions.This is because the infant may havenecrotizing enterocolitis (NEC), which is the most common cause of bloody stool in preterm infants.
NEC is a serious condition that involves inflammation and necrosis of the intestinal wall and can lead to perforation, sepsis, and death.NEC is also a potential source of infection for other infants in the NICU, so contact precautions are necessary to prevent cross-contamination.
Choice A is wrong because obtaining a rectal temperature is not indicated for an infant with bloody stool.Rectal temperature can cause irritation and bleeding of the rectal mucosa and can also increase the risk of perforation if there is intestinal necrosis.
Choice C is wrong because decreasing the amount of the feeding is not enough to manage an infant with bloody stool.
The infant may need to have the feeding stopped completely and receive parenteral nutrition until the bowel heals.Decreasing the feeding may also compromise the infant’s growth and development.
Choice D is wrong because assessing for abdominal distention is not a nursing action but a nursing assessment.
Abdominal distention is a common sign of feeding intolerance and NEC, but it is not specific or sensitive enough to diagnose the condition.Other signs and symptoms of NEC include bile-stained or bloody gastric residuals, emesis, diarrhea, temperature instability, apnea, bradycardia, hypotension, and lethargy.
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