Nokea
When should the nurse expect breastfeeding-associated jaundice to first appear in a normal infant?
- A. 2 to 12 hours
- B. 12 to 24 hours
- C. 2 to 4 days
- D. After the fifth day
Correct Answer: C
Rationale: Breastfeeding-associated jaundice is caused by decreased milk intake related to decreased caloric and fluid intake by the infant before the mothers milk is well established. Fasting is associated with decreased hepatic clearance of bilirubin. Zero to 24 hours is too soon; jaundice within the first 24 hours is associated with hemolytic disease of the newborn. After the fifth day is too late. Jaundice associated with breastfeeding begins earlier because of decreased breast milk intake.
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The nurse is caring for a breastfed full-term infant who was born after an uneventful pregnancy and delivery. The infants blood glucose level is 36 mg/dL. Which action should the nurse implement?
- A. Bring the infant to the mother and initiate breastfeeding.
- B. Place a nasogastric tube and administer 5% dextrose water.
- C. Start a peripheral intravenous line and administer 10% dextrose.
- D. Monitor the infant in the nursery and obtain a blood glucose level in 4 hours.
Correct Answer: A
Rationale: A full-term infant born after an uncomplicated pregnancy and delivery who is borderline hypoglycemic, as indicated by a blood glucose level of 36 mg/dL, and who is clinically asymptomatic should probably reestablish normoglycemia with early institution of breast or bottle feeding. The newborn does not require a nasogastric tube and 5% dextrose water or a peripheral intravenous line with 10% dextrose because the blood glucose level is only borderline. The infant does need to be monitored, but breastfeeding should be started and the blood glucose level checked in 1 to 2 hours.
When should the nurse expect jaundice to be present in a full-term infant with hemolytic disease?
- A. At birth
- B. Within 24 hours after birth
- C. 25 to 48 hours after birth
- D. 49 to 72 hours after birth
Correct Answer: B
Rationale: In hemolytic disease of the infant, jaundice is usually evident within the first 24 hours of life. Infants with hemolytic disease are usually not jaundiced at birth, although some degree of hepatosplenomegaly, pallor, and hypovolemic shock may occur when the most severe form, hydrops fetalis, is present. Twenty-five to 72 hours after birth is too late for hemolytic disease of the infant. Jaundice at these ages is most likely caused by physiologic or early-onset breastfeeding jaundice.
A woman who is Rh-negative is pregnant with her first child, and her husband is Rh positive. During her 12-week prenatal visit, she tells the nurse that she has been told that this is dangerous. What should the nurse tell her?
- A. That no treatment is necessary
- B. That an exchange transfusion will be necessary at birth
- C. That no treatment is available until the infant is born
- D. That administration of Rh immunoglobulin is indicated at 26 to 28 weeks of gestation
Correct Answer: D
Rationale: The goal is to prevent isoimmunization. If the mother has not been previously exposed to the Rh-negative antigen, Rh immunoglobulin (RhIg) is administered at 26 to 28 weeks of gestation and again within 72 hours of birth. The intramuscular administration of RhIg has virtually eliminated hemolytic disease of the infant secondary to the Rh factor. Unless other problems coexist, the newborn will not require transfusions at birth.
Which term is defined as a vaguely outlined area of edematous tissue situated over the portion of the scalp that presents in a vertex delivery?
- A. Hydrocephalus
- B. Cephalhematoma
- C. Caput succedaneum
- D. Subdural hematoma
Correct Answer: C
Rationale: Caput succedaneum is defined as a vaguely outlined area of edematous tissue situated over the portion of the scalp that presents in a vertex delivery. The swelling consists of serum or blood (or both) accumulated in the tissues above the bone, and it may extend beyond the bone margin. Hydrocephalus is caused by an imbalance in production and absorption of cerebrospinal fluid. When production exceeds absorption, fluid accumulates within the ventricular system, causing dilation of the ventricles. A cephalhematoma has sharply demarcated boundaries that do not extend beyond the limits of the (bone) suture line. A subdural hematoma is located between the dura and the cerebrum. It should not be visible on the scalp.
Which intervention may decrease the incidence of physiologic jaundice in a healthy full-term infant?
- A. Institute early and frequent feedings.
- B. Bathe newborn when the axillary temperature is 36.3 C (97.5 F).
- C. Place the newborns crib near a window for exposure to sunlight.
- D. Suggest that the mother initiate breastfeeding when the danger of jaundice has passed.
Correct Answer: A
Rationale: Physiologic jaundice is caused by the immature hepatic function of the newborns liver coupled with the increased load from red blood cell hemolysis. The excess bilirubin from the destroyed red blood cells cannot be excreted from the body. Feeding stimulates peristalsis and produces more rapid passage of meconium. Bathing does not affect physiologic jaundice. Placing the newborns crib near a window for exposure to sunlight is not a treatment of physiologic jaundice. Colostrum is a natural cathartic that facilitates meconium excavation.