A nurse is reviewing the medical record of a newborn who is 24 hr old. Which of the following findings requires intervention?

Weight loss of 3%

Voided one time since birth

Central cyanosis

Apical pulse rate of 156/min

Answer and Explanation

The Correct Answer is C

A. Weight loss of 3%:

Newborns commonly experience weight loss in the first few days of life due to factors such as loss of excess fluid and adjustment to feeding. A weight loss of up to 7-10% in the first week is considered normal. Therefore, a weight loss of 3% alone, while notable, is not typically concerning enough to require immediate intervention. However, it should be monitored closely to ensure that the newborn is receiving adequate nutrition and hydration.

B. Voided one time since birth:

Newborns typically pass urine within the first 24 hours after birth. However, the frequency of voiding can vary, and it is not uncommon for a newborn to void only once in the first 24 hours. While it is important for newborns to void regularly to ensure adequate hydration and renal function, voiding once in the first 24 hours may not necessarily indicate a problem, especially if the newborn is breastfeeding. Therefore, while this finding should be monitored, it may not require immediate intervention.

C. Central cyanosis:

Central cyanosis, characterized by bluish discoloration of the lips, tongue, and mucous membranes, indicates inadequate oxygenation of the blood. It suggests a potential respiratory or cardiac problem that requires immediate evaluation and intervention to ensure adequate oxygenation and prevent complications. Central cyanosis is a concerning finding in newborns and warrants prompt attention from healthcare providers to determine the underlying cause and initiate appropriate treatment.

D. Apical pulse rate of 156/min:

The normal range for a newborn's heart rate is typically 120-160 beats per minute. An apical pulse rate of 156/min falls within this range and is not necessarily indicative of a problem, especially if the newborn is active or crying. While variations in heart rate can occur, a rate of 156/min alone may not be alarming. However, it should be monitored for any changes or trends outside the normal range as part of routine newborn assessment.

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Correct Answer is B

Explanation

A. Turn the newborn every 4 hr:

Turning the newborn every 4 hours is a routine nursing intervention to prevent pressure ulcers in infants. However, it is not specifically related to phototherapy treatment. Turning the newborn should be done as per routine care, but it is not a direct action related to phototherapy.

B. Close the newborn's eyes before applying eyepatches:

It is important to protect the newborn's eyes from the bright light used in phototherapy. Therefore, closing the newborn's eyes before applying eyepatches or covering them with eye protection is necessary during phototherapy to prevent eye damage.

C. Provide the newborn with 15 mL glucose water after each feeding:

Providing glucose water after each feeding is not a standard practice for newborns undergoing phototherapy. Instead, the primary focus during phototherapy is on feeding the baby adequately to promote hydration and excretion of bilirubin through stool and urine. Glucose water is not routinely recommended unless specifically ordered by the healthcare provider for a medical indication.

D. Apply hydrating lotion to the newborn's skin prior to treatment:

Hydrating lotion should not be applied to the newborn's skin prior to phototherapy. Lotions, oils, or creams can interfere with the effectiveness of phototherapy by creating a barrier that blocks the light from reaching the baby's skin. Therefore, it is essential to keep the baby's skin clean and free from lotions or ointments during phototherapy.

A. Place a cool cloth at the site for 15 min before the procedure. B. Apply an alcohol pad to the site after the procedure. C. Puncture the lateral side of the heel for the procedure. D. Select a 21-gauge needle to perform the procedure.

Correct Answer is C

Explanation

A. Place a cool cloth at the site for 15 min before the procedure:

Placing a cool cloth at the site before the procedure is not typically done for a heel stick in newborns. In fact, applying cold to the site can cause vasoconstriction, which may make it more difficult to obtain an adequate blood sample. Additionally, cooling the area can potentially lead to discomfort for the newborn. Therefore, this action is not recommended and would not be appropriate in this scenario.

B. Apply an alcohol pad to the site after the procedure:

While alcohol pads are commonly used for disinfection before certain procedures, they are not typically used after a heel stick to obtain a blood sample for a total serum bilirubin test. Alcohol can interfere with bilirubin testing by altering the bilirubin levels in the blood, leading to inaccurate results. Therefore, applying an alcohol pad after the procedure is not recommended, particularly for bilirubin testing.

C. Puncture the lateral side of the heel for the procedure:

When performing a heel stick on a newborn, it is important to choose the appropriate site for puncture. The lateral side of the heel is preferred over the medial side because it has fewer nerves and blood vessels, reducing the risk of complications and discomfort for the newborn. Puncturing the lateral side also allows for a more controlled and successful blood draw. Therefore, this choice is the most appropriate for obtaining a blood sample for a total serum bilirubin test.

D. Select a 21-gauge needle to perform the procedure:

The choice of needle gauge for a heel stick in a newborn depends on various factors, including the size of the newborn's heel and the desired blood flow rate. However, a 21-gauge needle is relatively large and may cause more pain and tissue trauma compared to smaller gauge needles, especially in newborns. Smaller gauge needles, such as 23 or 25 gauge, are typically preferred for heel sticks in newborns to minimize discomfort and trauma to the tissue. Therefore, selecting a 21-gauge needle may not be the most appropriate choice for this procedure.

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A nurse is reviewing the medical record of a newborn who is 24 hr old. Which of the following findings requires intervention?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is B

Explanation

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Correct Answer is C

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