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
Explanation
Choice A rationale:
Appointing the client as a leader may not be appropriate, as individuals with antisocial personality disorder may misuse their position of authority.
Choice B rationale:
Clients with antisocial personality disorder often struggle with interpersonal relationships, may be manipulative, and may engage in behaviors that violate the rights of others. Monitoring the client's interactions with other clients helps ensure a safe and therapeutic environment while preventing harm to others.
Choice C rationale:
Offering warnings before consequences might not be effective with clients who have antisocial personality disorder, as they may disregard rules and consequences.
Choice D rationale:
Assigning a room near the activity area does not necessarily address the need to monitor the client's interactions with others.
Correct Answer is C
Explanation
Choice A rationale:
Ankle swelling can be a common symptom of pregnancy and is not necessarily indicative of a complication.
Choice B rationale:
Gums can become more sensitive during pregnancy, leading to bleeding while brushing teeth. This finding is common and not necessarily indicative of a complication.
Choice C rationale:
Constant pain in the middle of the upper abdomen can be a sign of preeclampsia, a serious pregnancy complication that requires prompt medical attention.
Choice D rationale:
Feeling dizzy when lying flat on the back (supine hypotension) can be a common discomfort during pregnancy due to pressure on the vena cava. However, it does not necessarily indicate a complication in this context.
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