An 18-hour-old baby with an elevated bilirubin level is placed under the bili lights.
Which of the following is an expected nursing action in these circumstances?
Give the baby oral rehydration therapy in place of all feedings.
Rotate the baby from side to back to side to front every 2 hours.
Apply restraints to keep the baby under the light source.
Administer intravenous fluids via pump per doctor orders.
The Correct Answer is B
Choice A rationale
Oral rehydration therapy is not used in place of feedings for infants undergoing phototherapy for elevated bilirubin levels. It's crucial to maintain proper nutrition and hydration through regular feedings.
Choice B rationale
Rotating the baby helps ensure even exposure to the bili lights, which aids in breaking down bilirubin effectively across the baby's body.
Choice C rationale
Applying restraints is inappropriate and unnecessary. It could cause distress and is not a standard practice for phototherapy.
Choice D rationale
Administering intravenous fluids is not typically needed unless there's a risk of dehydration or other medical indications as per the doctor's orders.
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Correct Answer is D
Explanation
Choice A rationale
Bleeding is typically not associated with a vaginal hematoma; it is more indicative of other postpartum complications such as uterine atony or retained placenta fragments.
Choice B rationale
Warmth is usually associated with infection or inflammation. A hematoma is a collection of clotted blood outside the blood vessels, not typically characterized by warmth.
Choice C rationale
Redness might be seen in cases of infection or inflammation. A vaginal hematoma is a localized collection of blood and does not inherently cause redness.
Choice D rationale
Pain is a common symptom of a vaginal hematoma due to the pressure and swelling from the accumulated blood.
Correct Answer is D
Explanation
Choice A rationale
Placental abruption is characterized by abdominal pain, vaginal bleeding, and uterine tenderness. It does not cause dyspnea, hypotension, frothy sputum, or loss of consciousness.
Choice B rationale
Uterine rupture typically presents with severe abdominal pain, abnormal fetal heart rate patterns, and vaginal bleeding. Shock can occur, but not frothy sputum or sudden dyspnea.
Choice C rationale
Uterine inversion leads to pain, hemorrhage, and shock. It does not present with frothy sputum or sudden dyspnea.
Choice D rationale
Anaphylactoid syndrome (amniotic fluid embolism) results from amniotic fluid entering maternal circulation, causing an anaphylactic reaction. Symptoms include sudden dyspnea, hypotension, frothy sputum, and loss of consciousness, matching the described scenario. .