A nurse is caring for the newborn 1 day after birth
Supplement feedings with dextrose water
Administer intravenous dextrose
Obtain a total serum bilirubin
Encourage breastfeeding every 2 hr
Prepare for an exchange transfusion
Obtain blood cultures
Correct Answer : C,D
A. Supplement feedings with dextrose water – Dextrose water is not appropriate for newborn feeding. It lacks the necessary calories and nutrients and is not recommended for managing hyperbilirubinemia or hydration.
B. Administer intravenous dextrose – There is no evidence of hypoglycemia or need for IV fluids. This is not indicated based on the current assessment.
C. Obtain a total serum bilirubin – The yellow sclera and cephalohematoma (from vacuum-assisted birth) place the newborn at risk for hyperbilirubinemia. A serum bilirubin level is needed to assess severity.
D. Encourage breastfeeding every 2 hr – This promotes bilirubin excretion through stools and urine, which is essential in managing or preventing jaundice in newborns.
E. Prepare for an exchange transfusion – This is a treatment for severe hyperbilirubinemia or hemolytic disease, and is not indicated at this stage without bilirubin results.
F. Obtain blood cultures – The mother received appropriate intrapartum prophylaxis (2 doses of penicillin G) for GBS. The newborn shows no signs of sepsis (vital signs normal, active, feeding), so cultures are not indicated now.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. Assessing cervical dilation is contraindicated due to risk of worsening bleeding with abruptio placenta.
B. Vaginal swabs for ferning test are used to assess rupture of membranes, not abruptio placenta.
C. Administering oxytocin can increase uterine contractions and worsen placental separation, so it is contraindicated.
D. Monitoring fetal heart rate tracings is essential to assess fetal well-being in cases of abruptio placenta.
Correct Answer is C
Explanation
A. History of ovarian cysts is not an absolute contraindication to oral contraceptives.
B. Hypotension is not a contraindication for oral contraceptives.
C. Migraine with aura is a contraindication due to increased risk of stroke associated with combined oral contraceptives in these clients.
D. Dysmenorrhea is often improved by oral contraceptive use and is not a contraindication.
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