A nurse is reviewing the transcutaneous bilirubin measurement of a newborn who is 48 hours old and has physiologic jaundice.
The measurement is 16 mg/dL.
Which of the following actions should the nurse take?
Initiate phototherapy immediately
Notify the provider to order a serum bilirubin test
Encourage the parent to feed the newborn more frequently
Reassure the parent that this is a normal finding
The Correct Answer is B
Transcutaneous bilirubin measurement is a useful screening tool for neonatal hyperbilirubinemia, but it has some limitations and sources of variability. Therefore, any bilirubin screening result obtained must be confirmed by a diagnostic method before treatment.
Choice A is wrong because initiating phototherapy without confirming the bilirubin level could expose the newborn to unnecessary treatment and potential adverse effects.
Choice C is wrong because increasing hydration by feeding more frequently may not be sufficient to lower the bilirubin level if it is too high or if there are other causes of jaundice.
Choice D is wrong because reassuring the parent that this is a normal finding could delay the diagnosis and treatment of severe neonatal hyperbilirubinemia, which can lead to serious complications such as kernicterus spectrum disorders.
Normal ranges for transcutaneous bilirubin measurement vary depending on the device used, the skin pigmentation, and the postnatal age of the newborn. However, a general guideline is that a measurement of 16 mg/dL at 48 hours of age is above the 95th percentile and warrants further investigation.
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 D
Explanation
Increased oxygen saturation.This indicates that the condition is improving because it means that the blood is getting more oxygen in the lungs and less blood is shunting from the aorta to the pulmonary artery through the patent ductus arteriosus (PDA).
Choice A is wrong because decreased heart rate can be a sign of hypoxia, acidosis, or heart failure, which are complications of PDA.
Choice B is wrong because increased blood pressure can be a sign of increased systemic vascular resistance, which can result from decreased tissue perfusion due to PDA.
Choice C is wrong because decreased respiratory rate can be a sign of respiratory depression, which can be caused by some medications used to treat PDA, such as indomethacin or ibuprofen.
Normal ranges for oxygen saturation in preterm infants are between 88% and 95%.
Normal ranges for heart rate in preterm infants are between 120 and 160 beats per minute.
Normal ranges for blood pressure in preterm infants depend on gestational age and weight.
Normal ranges for respiratory rate in preterm infants are between 40 and 60 breaths per minute.
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