A nurse is evaluating a newborn who has hyperbilirubinemia and is receiving phototherapy.
Which of the following outcomes indicates that the therapy is effective?
The newborn’s skin color is pink
The newborn’s stools are clay-colored
The newborn’s bilirubin level is 12 mg/dL
The newborn’s urine is dark yellow.
The Correct Answer is A
The newborn’s skin color is pink. This indicates that the phototherapy is effective in lowering the serum bilirubin level by transforming it into water-soluble isomers that can be eliminated without liver conjugation.
A pink skin color also means that the newborn is not jaundiced, which is a sign of high bilirubin levels.
Choice B is wrong because clay-colored stools indicate a problem with the liver or bile ducts. Bile is needed to give stools their normal brown color, and if bile is absent or blocked, the stools may become pale or clay-colored. This could be a sign of a serious condition such as biliary atresia, which is a congenital defect that causes bile ducts to be absent or malformed.
Choice C is wrong because a bilirubin level of 12 mg/dL is still high for a newborn and may require further treatment. The American Academy of Pediatrics recommends phototherapy for newborns with bilirubin levels above 15 mg/dL at 25 to 48 hours of age, 18 mg/dL at 49 to 72 hours of age, and 20 mg/dL at more than 72 hours of age. However, these thresholds may vary depending on the gestational age, risk factors, and clinical condition of the newborn.
Choice D is wrong because dark yellow urine may indicate dehydration or concentrated urine, which can increase the risk of bilirubin toxicity. Newborns receiving phototherapy should be well hydrated and have frequent wet diapers to help eliminate bilirubin from the body. Normal urine color for a newborn is pale yellow or clear.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Bronchospasm.
Bronchospasm is a constriction of the airways that causes wheezing and trouble breathing.It is one of the symptoms of anaphylaxis, a severe allergic reaction that can occur within minutes of exposure to something you’re allergic to, such as a bee sting.
Choice A is wrong because bradycardia is a slow heart rate, not a fast one.Anaphylaxis causes a weak and rapid pulse due to low blood pressure.
Choice B is wrong because hypertension is high blood pressure, not low.Anaphylaxis causes blood pressure to drop suddenly and can lead to shock.
Choice D is wrong because warm, dry skin is not a sign of anaphylaxis.Anaphylaxis causes skin reactions such as hives, itching, flushed or pale skin.
Correct Answer is C
Explanation
Corn tortillas.
Celiac disease is a condition that causes damage to the small intestine when gluten is ingested.
Gluten is a protein found in wheat, barley, rye and oats.
Corn tortillas are made from corn flour, which does not contain gluten and is safe for people with celiac disease.
Choice A is wrong because whole wheat bread contains gluten, which can trigger an immune response and damage the small intestine in people with celiac disease.
Choice B is wrong because oatmeal cookies also contain gluten, either from the oats themselves or from cross-contamination with other grains.
Choice D is wrong because barley soup contains barley, which is another source of gluten that can harm people with celiac disease.
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