A nurse is creating a plan of care for a newborn who is breastfed and appears jaundiced.
Which of the following interventions should the nurse include?
Place the newborn under a radiant warmer.
Supplement breastfeeding with iron-fortified formula.
Determine the effectiveness of breastfeeding.
Administer Rho(D) immune globin to the newborn.
The Correct Answer is C
Choice A rationale:
Placing the newborn under a radiant warmer is not directly related to addressing breastfeeding-related jaundice.
Choice B rationale:
Supplementing breastfeeding with formula is not the first-line approach and may interfere with establishing successful breastfeeding.
Choice C rationale:
Breastfeeding-related jaundice can occur if the newborn is not effectively breastfeeding and not getting enough milk. Assessing the effectiveness of breastfeeding is important to address the underlying cause of jaundice.
Choice D rationale:
Administering Rho(D) immune globulin is unrelated to addressing jaundice in a breastfed newborn.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A rationale:
Weight loss is not typically an expected manifestation following a total abdominal hysterectomy.
Choice B rationale:
Increased libido is not necessarily an expected manifestation following a total abdominal hysterectomy.
Choice C rationale:
Decreased menstrual bleeding is expected, as the uterus has been removed.
Choice D rationale:
Vaginal dryness is an expected manifestation following a total abdominal hysterectomy due to the removal of the ovaries, which produce hormones that contribute to vaginal lubrication.
Correct Answer is A
Explanation
Choice A rationale:
The client is experiencing signs of an allergic reaction or anaphylaxis, which can be life-threatening. The rapid response team should be called to provide immediate medical assistance.
Choice B rationale:
Intubation is not the immediate priority. Addressing the allergic reaction and ensuring the client's airway, breathing, and circulation are the first steps.
Choice C rationale:
Obtaining an arterial blood gas (ABG) level is not the priority when the client is experiencing respiratory distress and facial swelling.
Choice D rationale:
Administering diphenhydramine may be part of the treatment plan, but the immediate priority is to call for emergency assistance to manage the allergic reaction.
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