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
This is because late fetal heart rate decelerations are a sign of uteroplacental insufficiency, which means that the placenta is not delivering enough oxygen and nutrients to the fetus.Oxytocin can cause uterine tachysystole, which is excessive and frequent contractions that reduce blood flow to the placenta.Therefore, stopping the oxytocin infusion can help improve placental perfusion and fetal oxygenation.
Choice A is wrong because documenting the findings is not a priority action in this situation.
The nurse should first intervene to address the cause of late decelerations and then document the actions and outcomes.
Choice C is wrong because raising the head of the patient’s bed 30 degrees does not directly affect the placental blood flow or fetal oxygenation.
It may help with maternal comfort and breathing, but it is not an essential action for late decelerations.
Choice D is wrong because notifying the health care provider is not the first action to take.The nurse should first attempt to correct the cause of late decelerations by pausing the oxytocin infusion and then notify the health care provider if there is no improvement or if there are other signs of fetal distress.
Correct Answer is C
Explanation
The correct answer is choice C. Assess the client’s blood pressure.Methylergonovine is a uterotonic medication that can cause hypertension and is contraindicated for clients with preeclampsia or cardiac disease.
Therefore, the nurse should check the client’s blood pressure before administering this medication to ensure it is within normal range (120/80 mm Hg or lower).
Choice A is wrong because assessing the client’s pain scale is not a priority assessment before giving methylergonovine.
Pain is not a contraindication for this medication and does not affect its effectiveness.
Choice B is wrong because assessing the client’s respiratory rate is not a priority assessment before giving methylergonovine.
Respiratory rate is not affected by this medication and does not indicate any adverse effects.
Choice D is wrong because assessing the client’s last bowel movement is not a priority assessment before giving methylergonovine.
Bowel movement is not related to postpartum hemorrhage or uterine atony, which are the indications for this medication.
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