A nurse is preparing to administer an exchange transfusion to a newborn who has severe hyperbilirubinemia due to Rh incompatibility.
Which of the following actions should the nurse take first?
Obtain informed consent from the parent.
Check the newborn’s blood type and crossmatch.
Insert two umbilical catheters for blood withdrawal and infusion.
Monitor the newborn’s vital signs and oxygen saturation.
The Correct Answer is A
Exchange transfusion (ET) is a procedure that involves removing the infant’s blood and replacing it with compatible donor blood to reduce the level of bilirubin and/or antibody-coated red blood cells. It is a high-risk intervention that can cause serious complications such as vascular accidents, cardiovascular compromise, and electrolyte and hematologic derangement.
Therefore, it is essential to obtain informed consent from the parent before performing ET.
Choice B is wrong because checking the newborn’s blood type and crossmatch is not the first action the nurse should take.
Although it is important to ensure compatibility between the donor and recipient blood, it is not as urgent as obtaining informed consent.
Choice C is wrong because inserting two umbilical catheters for blood withdrawal and infusion is not the first action the nurse should take.
Although it is necessary to establish vascular access for ET, it is not as crucial as obtaining informed consent.
Choice D is wrong because monitoring the newborn’s vital signs and oxygen saturation is not the first action the nurse should take.
Although it is vital to assess the newborn’s condition before, during, and after ET, it is not as imperative as obtaining informed consent.
Normal ranges for bilirubin levels vary depending on the gestational age and postnatal age of the newborn. The American Academy of Pediatrics (AAP) has published nomograms for initiating phototherapy and ET based on these factors. According to the AAP, ET should be considered when the bilirubin level exceeds 25 mg/dL (428 μmol/L) in term infants or 20 mg/dL (342 μmol/L) in preterm infants with risk factors for neurotoxicity.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Encouraging frequent breastfeeding.
This is because breastfeeding provides glucose to the newborn baby, which can help prevent or treat hypoglycemia (low blood sugar).Hypoglycemia can cause problems such as shakiness, blue tint to the skin, and breathing and feeding problems.
Choice A is wrong because administering IV insulin would lower the blood sugar level even more, which could be dangerous for the baby.
Choice C is wrong because monitoring blood pressure is not directly related to hypoglycemia.
Blood pressure may be affected by other factors such as stress, infection, or dehydration.
Choice D is wrong because administering a hypertonic saline solution would increase the sodium level in the blood, which could cause dehydration and electrolyte imbalance.
A hypertonic saline solution is not a source of glucose for the baby.
Normal ranges for blood glucose levels in newborns are between 47 to 85 mg/dL.Hypoglycemia is defined as blood glucose below 47 mg/dL.
Correct Answer is A
Explanation
This statement indicates that the parent understands the signs of acute bilirubin encephalopathy, a serious complication of hyperbilirubinemia that can cause brain damage.
The parent should seek immediate medical attention if these symptoms occur.
Choice B is wrong because “I will keep my baby fully clothed and wrapped in blankets.” This statement indicates that the parent does not understand the role of phototherapy in treating hyperbilirubinemia.Phototherapy is a treatment wherein a baby is placed under a special blue spectrum light to reduce the bilirubin levels.The baby should be exposed to as much light as possible, with only the eyes and genitals covered.
Choice C is wrong because “I will limit breastfeeding to no more than 10 minutes per session.” This statement indicates that the parent does not understand the importance of adequate hydration and nutrition in preventing and treating hyperbilirubinemia.Breastfeeding should not be interrupted or limited, as it provides fluids and calories that help the baby excrete bilirubin through urine and stool.The American Academy of Pediatrics recommends breastfeeding at least 8 to 12 times per day for newborns.
Choice D is wrong because “I will avoid exposing my baby to sunlight or artificial light.” This statement indicates that the parent does not understand the difference between natural and artificial light sources for phototherapy.Sunlight or artificial light from lamps or windows are not effective or safe for treating hyperbilirubinemia, as they do not emit the right wavelength or intensity of light, and they can cause overheating, dehydration, sunburn, or eye damage.
The baby should receive phot
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.