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
Explanation
Choice A rationale
Hypoglycemia in a newborn, defined as a plasma glucose level typically below 40 to 50 mg/dL, starves the central nervous system of its primary energy source, glucose. This lack of fuel in the brain cells often presents with neurological symptoms. Jitteriness (or tremors) is a classic and early neurogenic sign of this metabolic disturbance, resulting from sympathetic nervous system activation.
Choice B rationale
Hypoglycemia typically results in an attempt by the body to conserve energy and may lead to poor peripheral perfusion and decreased metabolic rate, which often manifests as hypothermia (decreased temperature). Increased temperature (hyperthermia) is not a sign of hypoglycemia; instead, it is often associated with infection or environmental overheating.
Choice C rationale
Hypoglycemia causes central nervous system instability and depression, which generally results in a decrease in a newborn's reflexes and muscle tone (hypotonia), or can lead to lethargy and poor feeding. Therefore, brisk reflexes (hyperreflexia) are not a characteristic finding and would suggest other neurological or metabolic conditions.
Choice D rationale
The Moro reflex (or startle reflex) is a complex, primitive reflex that is present and intact in healthy newborns. While severe hypoglycemia can lead to generalized central nervous system depression, which could eventually suppress all reflexes, an absence of a Moro reflex is a more specific sign of a severe neurological injury or a congenital neurological disorder, not a typical early sign of hypoglycemia.
Correct Answer is B
Explanation
Choice A rationale
The Babinski reflex is a primitive neurological reflex tested by stroking the sole of the foot. A normal response in a newborn is fanning of the toes, which indicates an intact central nervous system. This reflex, though important for neurological assessment, does not provide immediate data for evaluating respiratory or muscle tone complications, which are assessed by other parameters.
Choice B rationale
Heart rate is a critical component of the Apgar score, along with muscle tone, reflex irritability, color, and respiration. A low or declining heart rate (normal range 120-160 beats/min in a newborn) is often an early and sensitive indicator of hypoxia, circulatory compromise, or significant physiological distress, making it essential for immediate complication assessment.
Choice C rationale
The Moro reflex (startle reflex) is a primitive reflex observed by a sudden change in position. Its presence indicates neurological integrity. While its absence could signal a neurological or musculoskeletal injury, it is not an immediate parameter used for rapid assessment of cardiorespiratory stability in a distressed newborn like heart rate or blood glucose.
Choice D rationale
Blood glucose (normal 40-60 mg/dL) is important for energy homeostasis, and hypoglycemia can lead to lethargy, hypotonia, and respiratory distress. However, it is not as rapid or direct a measure of immediate oxygenation and perfusion status as the heart rate and respiratory effort are for determining acute complications.
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