A nurse is caring for a newborn 4 hours after birth. Which of the following actions should the nurse include in the plan of care to prevent jaundice?
Monitor blood glucose levels frequently.
Begin phototherapy immediately.
Initiate early feeding.
Prepare for a blood transfusion.
The Correct Answer is C
Choice A rationale
Monitoring blood glucose levels frequently is important for newborns, especially those at risk for hypoglycemia. However, it does not directly prevent jaundice. Jaundice is caused by elevated bilirubin levels, which are not directly related to blood glucose levels.
Choice B rationale
Beginning phototherapy immediately is a treatment for jaundice, not a preventive measure. Phototherapy is used to reduce high bilirubin levels in newborns who already have jaundice.
Choice C rationale
Initiating early feeding is an effective way to prevent jaundice in newborns. Early feeding helps promote regular bowel movements, which aids in the excretion of bilirubin from the body, thereby reducing the risk of jaundice.
Choice D rationale
Preparing for a blood transfusion is a treatment for severe jaundice, not a preventive measure. Blood transfusions are used in cases of extreme hyperbilirubinemia that do not respond to other treatments.
Free Nursing Test Bank
- Free Pharmacology Quiz 1
- Free Medical-Surgical Quiz 2
- Free Fundamentals Quiz 3
- Free Maternal-Newborn Quiz 4
- Free Anatomy and Physiology Quiz 5
- Free Obstetrics and Pediatrics Quiz 6
- Free Fluid and Electrolytes Quiz 7
- Free Community Health Quiz 8
- Free Promoting Health across the Lifespan Quiz 9
- Free Multidimensional Care Quiz 10
View Related questions
Correct Answer is B
Explanation
Choice A rationale
An inwardly turned foot is not a sign of DDH. It may indicate a different condition such as clubfoot.
Choice B rationale
Asymmetrical gluteal folds are a common sign of developmental dysplasia of the hip (DDH). This occurs because the hip joint is not properly aligned, causing uneven skin folds.
Choice C rationale
The absence of the Babinski sign is not related to DDH. The Babinski sign is a reflex test used to assess neurological function.
Choice D rationale
The absence of the stepping reflex is not related to DDH. The stepping reflex is a normal newborn reflex that disappears after a few months.
Correct Answer is D
Explanation
Choice A rationale
The xiphoid process is not the correct anatomical landmark for measuring chest circumference in newborns. It is located at the lower end of the sternum and does not provide a consistent measurement point.
Choice B rationale
The fifth intercostal space is not used for measuring chest circumference in newborns. This space is located between the ribs and is not a reliable landmark for consistent measurements.
Choice C rationale
The sternal notch is not the correct landmark for measuring chest circumference. It is located at the top of the sternum and does not provide a consistent measurement point.
Choice D rationale
The nipple line is the correct anatomical landmark for measuring chest circumference in newborns. This method ensures that the measurement is taken at a consistent and reproducible location, providing an accurate assessment of the chest size relative to growth and development standards.