The nurse evaluates a 10-hour-old newborn who is B-negative blood type and whose mother is O+. The nurse assesses the newborn to have noticeable yellow discoloration of the skin.
The nurse reports this as pathologic jaundice and understands that which finding is most helpful in reducing jaundice in the infant?
Frequent bowel movements.
A stable temperature of 98.0°F axillary.
6-8 voids in a 24-hour period.
A heel stick of 60.
The Correct Answer is A
Choice A rationale
Frequent bowel movements help excrete bilirubin, which reduces jaundice. Newborns pass meconium and transitional stools frequently, aiding in bilirubin clearance.
Choice B rationale
A stable temperature is important for overall health, but it does not specifically impact bilirubin levels or jaundice.
Choice C rationale
A newborn should have 6-8 voids per day indicating good hydration, but it is not directly related to reducing jaundice.
Choice D rationale
A heel stick with a glucose level of 60 may indicate glucose monitoring but is not related to jaundice management.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["0.43"]
Explanation
Step 1 is 4300 grams ÷ 1000 = 4.3 kg.
Step 2 is 4.3 kg × 2 mg = 8.6 mg.
Step 3 is 8.6 mg ÷ (20 mg ÷ 1 ml) = 0.43 ml.
Answer: 0.43 ml.
Correct Answer is C
Explanation
Choice A rationale
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Normal neonatal glucose: >45 mg/dL (ideally 50–110 mg/dL).
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A level of 40 is low → risk for hypoglycemia complications (seizures, brain injury).
While it is important to monitor glucose levels, a reading of 40 mg/dL is low and requires immediate attention. Waiting 4 hours could allow the newborn's condition to deteriorate further. Hypoglycemia in newborns can lead to serious complications if not treated promptly.
Choice B rationale
Assessing for hypothermia is essential, but it is not the first priority when a newborn has low blood glucose levels. Immediate steps should be taken to address the hypoglycemia to prevent further complications, as it is a more immediate threat to the newborn's health.
Choice C rationale
Notifying the physician on call is the correct priority intervention. A blood glucose level of 40 mg/dL is concerning, and prompt medical intervention is necessary. The physician can order appropriate treatment to stabilize the newborn's glucose levels and prevent potential complications.
Choice D rationale
Re-evaluating the blood serum glucose is important but comes after initiating immediate intervention. Continuous monitoring should follow initial treatment to ensure the newborn's glucose levels stabilize. Immediate action is crucial to address the hypoglycemia effectively.
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