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 ["B","C","D"]
Explanation
Choice A rationale:
Asking the client to explain what she is hearing may not be helpful, as the client's perception of the hallucinations may not match reality.
Choice B rationale:
Conveying empathy is important to establish a therapeutic relationship and provide emotional support.
Choice C rationale:
Encouraging the client to listen to music through headphones can help distract from auditory hallucinations.
Choice D rationale:
Speaking simply and clearly when communicating helps the client understand and process information more effectively.
Choice E rationale:
Using therapeutic touch might not be appropriate for all clients and should be based on the client's preferences and comfort level.
Correct Answer is A
Explanation
Choice A rationale:
Assessing for the presence of command hallucinations is a priority, as they can pose a risk to the client's safety and the safety of others.
Choice B rationale:
Consistent staff assignments can be important for clients with schizophrenia, but immediate safety concerns should take precedence.
Choice C rationale:
Administering medication is not the priority action unless there is a specific reason to do so based on the assessment.
Choice D rationale:
Using the client's name is respectful and helpful, but it is not the priority action in this scenario.
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