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 B
Explanation
Choice A rationale
Administering only the Hepatitis B vaccine within 1 hour of birth is not sufficient for a newborn born to a Hepatitis B positive mother. The newborn also needs Hepatitis B immunoglobulin (HBIG) to provide immediate passive immunity.
Choice B rationale
Administering both the Hepatitis B vaccine and Hepatitis B immunoglobulin (HBIG) within 12 hours of delivery is the recommended practice for newborns born to Hepatitis B positive mothers. This provides both active and passive immunity.
Choice C rationale
Administering only Hepatitis B immunoglobulin (HBIG) within 12 hours of birth is not sufficient. The newborn also needs the Hepatitis B vaccine to develop long-term immunity.
Choice D rationale
Administering Hepatitis B immunoglobulin (HBIG) within 12 hours, followed by monthly Hepatitis B vaccines for 12 months, is not the standard practice. The newborn should receive the Hepatitis B vaccine series according to the recommended schedule. .
Correct Answer is D
Explanation
Choice A rationale
A respiratory rate of 110/min is too high for a newborn and may indicate respiratory distress.
Choice B rationale
A respiratory rate of 100/min is also too high for a newborn and may indicate respiratory distress.
Choice C rationale
A respiratory rate of 24/min is too low for a newborn and may indicate respiratory depression.
Choice D rationale
The normal respiratory rate for a newborn is between 30 to 60 breaths per minute. A rate of 60/min is within this range.