Exhibits
The nurse has reviewed the I&O and Diagnostic Results from Day 2. Select the 2 orders the nurse should anticipate the provider to prescribe.
Wake the newborn to breastfeed every 2 hr.
Supplement feedings with sterile water.
Obtain blood cultures.
Prepare for an exchange transfusion.
Obtain a total bilirubin level.
Correct Answer : A,E
Choice A rationale: Frequent breastfeeding every 2 hours enhances bilirubin excretion by promoting hydration and stooling. Bilirubin is eliminated via feces, and increased feeding stimulates gastrointestinal motility. Breast milk also supports hepatic conjugation of bilirubin. In late preterm infants, feeding cues may be subtle, so scheduled waking ensures intake adequacy. This intervention is critical in managing hyperbilirubinemia conservatively and preventing escalation to invasive treatments such as exchange transfusion.
Choice B rationale: Sterile water lacks calories and nutrients, and does not promote bilirubin excretion. It may dilute serum sodium and increase the risk of water intoxication. Newborns require energy-dense feeds to support hepatic function and bowel activity. Supplementation with sterile water is contraindicated in hyperbilirubinemia management. Instead, formula or breast milk should be used to ensure adequate caloric intake and hydration, both of which are essential for bilirubin clearance.
Choice C rationale: Blood cultures are indicated when sepsis is suspected. In this case, the newborn is afebrile, vigorous, and has stable vital signs. Hyperbilirubinemia alone does not warrant blood cultures unless accompanied by signs of infection such as temperature instability, lethargy, or poor perfusion. The absence of systemic symptoms and a known cause (birth trauma, prematurity) makes sepsis unlikely. Therefore, blood cultures are not anticipated at this stage.
Choice D rationale: Exchange transfusion is reserved for severe hyperbilirubinemia unresponsive to phototherapy or when bilirubin levels approach neurotoxic thresholds. The American Academy of Pediatrics recommends exchange transfusion when bilirubin exceeds 25 mg/dL or if signs of acute bilirubin encephalopathy are present. This newborn’s bilirubin peaked at 18.5 mg/dL and decreased to 14.2 mg/dL with phototherapy, indicating effective response. Thus, exchange transfusion is not currently indicated.
Choice E rationale: Serial bilirubin monitoring is essential to assess treatment efficacy and guide phototherapy duration. The newborn’s bilirubin decreased from 18.5 mg/dL to 14.2 mg/dL, but continued monitoring is needed to ensure sustained improvement and prevent rebound hyperbilirubinemia. Total serum bilirubin levels provide accurate quantification and help determine whether phototherapy can be discontinued or adjusted. This order supports safe, evidence-based management of neonatal jaundice.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","C","D","G"]
Explanation
Choice A rationale: Skin-to-skin contact promotes thermoregulation, stabilizes heart rate and respiratory rate, and enhances glucose homeostasis through reduced stress hormone release. It also facilitates breastfeeding by stimulating maternal oxytocin and infant rooting reflexes. In hypoglycemic newborns, skin-to-skin reduces energy expenditure and supports metabolic recovery. This intervention is evidence-based and essential for physiologic stabilization and bonding, especially in infants with feeding difficulties or temperature instability.
Choice B rationale: Rechecking glucose levels is critical to confirm sustained euglycemia and detect rebound hypoglycemia. Neonatal glucose regulation is dynamic, especially in large-for-gestational-age infants. After initial correction, glucose may drop again due to persistent hyperinsulinemia. Monitoring ensures timely intervention and prevents neurologic sequelae. The normal range for neonatal blood glucose is greater than 40 to 45 mg/dL. Serial checks guide feeding frequency and determine need for escalation of care.
Choice C rationale: Temperature monitoring is essential because hypothermia increases glucose utilization and exacerbates hypoglycemia. Newborns have immature thermoregulatory mechanisms and rely on external warmth and brown fat metabolism. A stable temperature of 36.5° C (97.7° F) is ideal. Rechecking ensures that swaddling and skin-to-skin are effective and that no environmental factors are compromising thermal stability. Temperature instability may signal underlying metabolic or infectious processes requiring further evaluation.
Choice D rationale: Reinforcing hourly breastfeeding supports frequent glucose intake and prevents hypoglycemia recurrence. Early and regular feeding is the cornerstone of neonatal glucose management. Hourly feeding ensures adequate caloric delivery, stimulates gastrointestinal motility, and promotes bilirubin excretion. It also helps establish maternal milk supply and improves latch technique through repetition. This action is especially important in infants with initial feeding difficulties or borderline glucose levels.
Choice E rationale: Tightly swaddling provides warmth and comfort but is not a primary intervention once temperature is stable. While swaddling supports thermoregulation and reduces energy expenditure, it does not directly address glucose regulation or feeding. In this case, the newborn’s temperature has normalized, and swaddling has already been implemented. Therefore, it is not a next-step priority but rather a maintenance measure.
Choice F rationale: Maintaining an IV catheter is unnecessary unless glucose levels remain critically low or feeding fails. The newborn’s glucose improved to 50 mg/dL after breastfeeding, indicating effective oral management. IV glucose is reserved for symptomatic hypoglycemia or levels below 25 mg/dL. In this stable scenario, invasive therapy is not warranted and may introduce infection risk or parental anxiety. Thus, it is not an appropriate next action.
Choice G rationale: Scheduling a lactation consult addresses the initial difficulty with latching and supports long-term feeding success. Lactation specialists provide hands-on guidance, assess anatomical barriers, and educate on positioning and milk transfer. Early intervention improves breastfeeding outcomes and reduces risk of hypoglycemia, dehydration, and jaundice. This consult is especially important for large infants with high metabolic demands and mothers needing support.
Choice H rationale: Monitoring for dehydration is important but not immediately indicated unless signs such as poor skin turgor, dry mucosa, or decreased urine output appear. The newborn has breastfed and is sleeping quietly, suggesting adequate hydration. While vigilance is necessary, it is not a top-five priority at this moment. Dehydration monitoring becomes more relevant if feeding remains poor or output declines.
Choice I rationale: Supplemental oxygen is not indicated in a newborn with normal respiratory rate, heart rate, and oxygen saturation. The newborn is alert, crying, and has no retractions or cyanosis. Oxygen therapy is reserved for hypoxemia or respiratory distress. Unnecessary oxygen can suppress respiratory drive and interfere with thermoregulation. Therefore, it is not appropriate in this stable clinical context.
Correct Answer is A
Explanation
Choice A rationale
Applying witch hazel compresses (such as Tucks pads) is an effective and preferred action for postpartum perineal discomfort, including episiotomy pain. Witch hazel contains tannins and volatile oils that provide an astringent and anti-inflammatory effect. This action helps to reduce swelling, soothe the tissues, and offer immediate, localized pain relief at the episiotomy site.
Choice B rationale
Administering aspirin (acetylsalicylic acid) for postpartum discomfort is generally contraindicated. Aspirin is a non-steroidal anti-inflammatory drug (NSAID) with antiplatelet effects, which could increase the risk of bleeding postpartum, especially from the placental insertion site or the episiotomy wound. Preferred analgesics are typically acetaminophen or ibuprofen, which have less impact on coagulation.
Choice C rationale
Having the client use a warm pack is not the initial treatment for episiotomy pain within the first 24 hours. Heat promotes vasodilation, which can increase edema and pain in the acutely inflamed and traumatized tissues. Cold therapy (e.g., ice packs) is the standard initial treatment because it causes vasoconstriction, which minimizes swelling and provides a local anesthetic effect.
Choice D rationale
Instructing the client to sit on a soft pillow might seem helpful, but it can sometimes be detrimental. Sitting on a soft, ring-shaped, or inflated pillow can cause the client to press outward on the soft tissues of the perineum, potentially increasing pressure and discomfort on the episiotomy incision. Sitting on a firm surface with the buttocks shifted can be more comfortable for some.
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