Which physical signs could indicate a risk for hyperbilirubinemia?

Choice A reason:

Drying the newborn's skin thoroughly is the nurse's priority after assuring a patent airway because it reduces evaporative heat loss by the newborn and prevents cold stress. Cold stress can lead to hypoxia, hypoglycemia, acidosis, and increased bilirubin levels. Drying the newborn also stimulates breathing and crying, which are signs of a healthy newborn.

Choice B reason:

Administering phytonadione IM is not the nurse's priority because it is not an immediate life-saving intervention. Phytonadione is given to prevent hemorrhagic disease of the newborn, which is caused by vitamin K deficiency. However, this condition usually occurs after the first day of life, so administering phytonadione can be delayed until after the initial assessment and stabilization of the newborn.

Choice C reason:

Documenting the Apgar score is not the nurse's priority because it is not an action that directly affects the newborn's well-being. The Apgar score is a tool to assess the newborn's condition at 1 and 5 minutes after birth based on five criteria: heart rate, respiratory effort, muscle tone, reflex irritability, and color. The Apgar score can help guide the nurse's interventions, but it is not more important than providing care to the newborn.

Choice D reason:

Applying identification bands is not the nurse's priority because it is not an urgent or essential action. Identification bands are used to ensure the safety and security of the newborn and prevent errors or mix-ups. However, applying identification bands can be done after the newborn is dried, warmed, and assessed for any problems.

A. Discard unused formula in used bottle after 2 hours:Once a baby has started drinking from a bottle, bacteria from the baby’s mouth can contaminate the formula. Any leftover formula should be discarded after 2 hours to prevent bacterial growth and reduce the risk of infection.

B. Never prop a bottle:Propping a bottle can lead to choking, ear infections, and dental issues (such as baby bottle tooth decay). Babies should always be held upright during feedings.

C. Formula is available in three forms:Infant formula is available in three types:Ready-to-feed (no mixing needed),Liquid concentrate (mix with water),Powdered formula (mix with water).

E. Store prepared bottles in the refrigerator:If formula is prepared in advance, it must be stored in the refrigerator (≤ 4°C or 40°F) and used within 24 hours to prevent bacterial growth.

Incorrect Answer:

D. Warm the bottle in the microwave:Microwaving heats unevenly, creating hot spots that can burn the baby’s mouth. Instead, warm bottles by placing them in warm water for a few minutes and always test the temperature on the wrist before feeding.