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 B
Explanation
Choice A rationale
Applying warm packs during the initial 24 hours postpartum is generally contraindicated for an episiotomy site. Heat promotes vasodilation, which could increase swelling and edema in the traumatized perineal tissues, exacerbating pain and potentially increasing blood loss. Cold therapy, such as ice packs, is the preferred intervention initially, as it causes vasoconstriction, reducing localized edema and numbing the area for pain relief.
Choice B rationale
Encouraging the client to take a sitz bath twice daily is an appropriate intervention for an episiotomy, typically after the first 24 hours postpartum when the initial swelling has subsided. The warm water promotes vasodilation, which improves circulation to the perineal area. This enhanced blood flow facilitates healing and offers soothing relief from pain and discomfort, aiding in tissue regeneration and cleanliness.
Choice C rationale
Applying antibiotic ointment to a routine episiotomy is generally not recommended unless there are signs of infection or a specific prescription is provided. The wound is clean, and the risk of introducing pathogens outweighs the routine benefit. Proper hygiene with cleansing after elimination, using a peri-bottle with warm water, and changing pads frequently is the standard of care to prevent infection and promote natural healing.
Choice D rationale
Instructing the client to wipe the perineum with toilet tissue after voiding is incorrect and can be detrimental to episiotomy healing. Wiping, particularly from back to front, can introduce fecal bacteria into the episiotomy site or vagina, increasing the risk of infection. The client should be instructed to use a peri-bottle filled with warm water to gently rinse the area after elimination and then pat dry with a clean cloth or tissue.
Correct Answer is {"dropdown-group-1":"A","dropdown-group-2":"A"}
Explanation
Heel warming increases capillary blood flow, improving sample accuracy and reducing hemolysis risk. Capillary glucose testing requires adequate perfusion for reliable results. Breastfeeding provides immediate glucose substrate to correct mild hypoglycemia. Normal neonatal blood glucose is >40–45 mg/dL; this newborn’s initial level of 35 mg/dL is below threshold, but responsive to feeding. Breast milk contains lactose, metabolized to glucose and galactose, supporting cerebral energy demands.
Rationale for incorrect Response 1 options: Administer glucose gel is appropriate only if feeding fails or glucose remains <25 mg/dL in asymptomatic or <40 mg/dL in symptomatic neonates. This newborn improved with feeding. Start IV fluids is reserved for persistent hypoglycemia or symptomatic neonates unresponsive to oral intake. The newborn stabilized post-breastfeeding. Phototherapy treats hyperbilirubinemia, not hypoglycemia. No bilirubin levels or jaundice signs were reported.
Rationale for incorrect Response 2 options: Supplement with formula is secondary to breastfeeding unless maternal milk is unavailable or ineffective. Breastfeeding was successful post-latch correction. Administer insulin is contraindicated; insulin lowers glucose and is used only in hyperglycemia. Monitor for jaundice is unrelated to hypoglycemia management unless bilirubin levels are elevated. No clinical jaundice was noted.
Take-home points:
- Neonatal hypoglycemia is defined as glucose <40–45 mg/dL; early feeding is first-line intervention.
- Macrosomic infants (birth weight >4,000 g) are at risk due to hyperinsulinemia post-placental glucose withdrawal.
- Differentiate hypoglycemia from sepsis, hypothermia, and metabolic disorders—all may present with jitteriness and hypotonia.
- Capillary sampling requires heel warming to ensure perfusion and accurate glucose measurement.
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