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.
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Correct Answer is D
Explanation
Choice A rationale
Hyperbilirubinemia, or high levels of bilirubin in the blood, can occur in newborns of diabetic mothers due to increased red blood cell breakdown. However, it is not the primary concern immediately after birth. The priority is to address conditions that can cause immediate harm, such as hypoglycemia.
Choice B rationale
Hypomagnesemia, or low magnesium levels, can occur in newborns of diabetic mothers, but it is not the most critical issue. Magnesium levels can be monitored and corrected if necessary, but hypoglycemia poses a more immediate threat to the newborn’s health.
Choice C rationale
Hypocalcemia, or low calcium levels, can also occur in newborns of diabetic mothers. While it is important to monitor and manage calcium levels, hypoglycemia is a more urgent concern because it can lead to severe complications if not addressed promptly.
Choice D rationale
Hypoglycemia, or low blood sugar levels, is the most critical concern for newborns of diabetic mothers. These newborns are at high risk for hypoglycemia due to the high levels of insulin they produce in response to their mother’s elevated blood glucose levels during pregnancy. Hypoglycemia can cause serious complications, including seizures and brain damage, if not treated immediately.
Correct Answer is D
Explanation
Choice A rationale
Newborns are not born with fully developed immune responses. Their immune system is immature and continues to develop after birth. They rely on maternal antibodies for initial protection.
Choice B rationale
Newborns do not have a mature gut microbiome immediately after birth. The gut microbiome develops over time and is influenced by factors such as breastfeeding and exposure to the environment.
Choice C rationale
Newborns do not rely solely on their innate immune system. They receive passive immunity from maternal antibodies transferred through the placenta and colostrum, which provides initial protection against infections.
Choice D rationale
Newborns receive passive immunity through the placenta and colostrum, but their own immune system is not fully functional until several months of age. This passive immunity helps protect them from infections during the early months of life.