The nursery nurse is receiving a report on her assigned 4 neonates. Which of the following conditions is high risk for unconjugated bilirubin and jaundice?
Microcephaly.
Polydactyly.
Caput succedaneum.
Cephalohematoma.
The Correct Answer is D
Choice A rationale
Microcephaly is not typically associated with an increased risk of unconjugated bilirubin and jaundice.
Choice B rationale
Polydactyly is a congenital condition involving extra fingers or toes and is not associated with an increased risk of unconjugated bilirubin and jaundice.
Choice C rationale
Caput succedaneum is a condition involving swelling of the scalp in a newborn and is not typically associated with an increased risk of unconjugated bilirubin and jaundice.
Choice D rationale
Cephalohematoma is a collection of blood between a baby’s scalp and the skull bone. It is associated with an increased risk of unconjugated bilirubin and jaundice due to the breakdown of red blood cells in the hematoma. .
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Correct Answer is C
Explanation
Choice A rationale
Faint red marks on the plantar surface are more common in preterm infants and are not typically seen in post-term infants.
Choice B rationale
Copious vernix is usually seen in preterm infants. Post-term infants often have little to no vernix.
Choice C rationale
Dry, cracked skin is a common finding in post-term infants due to prolonged exposure to the amniotic fluid.
Choice D rationale
Scant scalp hair is more common in preterm infants. Post-term infants usually have more developed hair.
Correct Answer is A
Explanation
Choice A rationale
Given the neonate’s symptoms and critically low blood glucose level (30 mg/dL), the most urgent action is to address the hypoglycemia. Therefore, the nurse shouldadminister a bolus of intravenous glucose (Option A). This immediate intervention is crucial to stabilize the neonate and prevent further complications associated with hypoglycemia.
Choice B rationale
While monitoring blood glucose levels is important, waiting 30 minutes to reassess without immediate intervention could allow the hypoglycemia to worsen, potentially leading to severe complications such as seizures or brain damage. Immediate treatment is necessary to stabilize the neonate.
Choice C rationale
Although feeding can help increase blood glucose levels, the neonate’s current symptoms (jitteriness, poor feeding, weak cry, and irritability) suggest that they may not be able to effectively feed. Additionally, the blood glucose level is critically low and requires more rapid correction than feeding alone can provide.
Choice D rationale
While maintaining an appropriate body temperature is important, the neonate’s temperature (36.1°C) is not critically low. The primary concern here is the hypoglycemia, which needs to be addressed immediately. Placing the neonate under a radiant warmer does not directly address the low blood glucose level.