On her second postpartum day, the mother of a newborn says, “The doctor says the baby has physiologic jaundice.
Even though it is supposed to be normal, I don’t understand why it occurs.” Which fact regarding physiologic jaundice should form the basis of the nurse’s response?
It is caused by an increase in neonatal metabolism.
It is related to the destruction of fetal red blood cells.
It is caused by an antigen-antibody reaction.
It is related to the immaturity of the reticuloendothelial system.
The Correct Answer is B
Physiologic jaundice is a common condition in newborns that occurs when the baby’s blood contains an excess of bilirubin, a yellow pigment produced during the normal breakdown of red blood cells.In the womb, the mother’s liver removes bilirubin for the baby, but after birth the baby’s own liver must take over this function.Because the baby has more red blood cells than an adult and their liver is still immature, they may not be able to process all the bilirubin and it may build up in their skin and eyes, causing a yellowish appearance.
Choice A is wrong because it is not an increase in neonatal metabolism that causes physiologic jaundice, but rather a decrease in hepatic metabolism of bilirubin.
Choice C is wrong because it describes a different type of jaundice called hemolytic jaundice, which occurs when there is an incompatibility between the blood types of the mother and the baby, leading to an immune reaction that destroys the baby’s red blood cells faster than they can be replaced.
Choice D is wrong because it confuses the reticuloendothelial system with the hepatic system.
The reticuloendothelial system is a network of cells and tissues that are involved in immune responses and phagocytosis (the ingestion of foreign particles or cells).
The hepatic system is the system of organs and structures that are involved in liver functions, such as bile production and detoxification.
Normal ranges for bilirubin levels in newborns are 1 to 12 mg/dL (17 to 205 micromol/L) for total bilirubin and 0.2 to 1.4 mg/dL (3 to 24 micromol/L) for direct bilirubin.
Physiologic jaundice usually peaks at 3 to 5 days after birth and resolves by 2 weeks of age.
It does not require treatment unless the bilirubin levels are very high or rising rapidly, which may indicate a more serious condition or a risk of brain damage.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Massaging the uterus helps it contract and prevent excessive bleeding after delivery.Uterine atony is a condition where the uterus does not contract enough to clamp the blood vessels that supply the placenta, leading to postpartum hemorrhage.Uterine massage is one of the interventions to treat uterine atony and restore uterine tone.
Choice A is wrong because having the client void frequently does not directly affect the uterine contraction.However, a full bladder can interfere with uterine contraction and cause displacement of the uterus, so it is important to monitor the bladder status and empty it as needed.
Choice C is wrong because having the client in a side-lying position for comfort does not help with uterine contraction.However, this position may be beneficial for other reasons, such as reducing edema and pain in the perineal area.
Choice D is wrong because keeping the patient on strict bed rest for 24 hours to avoid stress on the uterus does not help with uterine contraction.In fact, early ambulation after delivery can help prevent thromboembolic complications and promote recovery.
Normal ranges for postpartum blood loss are less than 500 mL for vaginal delivery and less than 1000 mL for cesarean delivery.Postpartum hemorrhage is defined as blood loss greater than or equal to 1000 mL or blood loss accompanied by signs or symptoms of hypovolemia within 24 hours after birth.
Correct Answer is C
Explanation
The correct answer is choice C. Count the time from the beginning of one contraction to the end of the same contraction.
This is because the duration of a contraction is the length of time that the uterine muscle is tightening and relaxing.
The duration is measured from the start of one contraction until the end of that same contraction.
Choice A is wrong because it measures the frequency of contractions, not the duration.
The frequency is the time between the start of one contraction and the start of the next one.
Choice B is wrong because it measures only half of the duration of a contraction.
The middle of a contraction is when the uterine muscle reaches its peak intensity and then starts to relax.
Choice D is wrong because it measures both the duration and the interval of contractions.
The interval is the time between the end of one contraction and the start of the next one.
Normal ranges for contractions during labor are:
• Duration: 30 to 90 seconds
• Frequency: 2 to 5 minutes apart
• Interval: 30 to 120 seconds
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