Nokea
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.
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A newborn has been diagnosed with brachial nerve paralysis. The nurse should assist the breastfeeding mother to use which hold or position during feeding?
- A. Reclining
- B. The cradle hold
- C. The football hold
- D. The cross-over hold
Correct Answer: C
Rationale: In brachial nerve paralysis, the affected arm is gently immobilized on the upper abdomen. Tucking the newborn under the arm (football hold) puts less pressure on the newborns affected extremity. The other positions place the newborns body next to the mothers and can cause pressure on the affected arm.
A mother is upset because her newborn has erythema toxicum neonatorum. The nurse should reassure her that this is what?
- A. Easily treated
- B. Benign and transient
- C. Usually not contagious
- D. Usually not disfiguring
Correct Answer: B
Rationale: Erythema toxicum neonatorum, or newborn rash, is a benign, self-limiting eruption of unknown cause that usually appears within the first 2 days of life. The rash usually lasts about 5 to 7 days. No treatment is indicated. Erythema toxicum neonatorum is not contagious. Successive crops of lesions heal without pigmentation.
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.
Rh hemolytic disease is suspected in a mothers second baby, a son. Which factor is important in understanding how this could develop?
- A. The first child was a girl.
- B. The first child was Rh positive.
- C. Both parents have type O blood.
- D. She was not immunized against hemolysis.
Correct Answer: B
Rationale: Hemolytic disease of the newborn results from an abnormally rapid rate of red blood cell (RBC) destruction. The major causes of this are maternal-fetal Rh and ABO incompatibility. If an Rh-negative mother has previously been exposed to Rh-positive blood through pregnancy or blood transfusion, antibodies to this blood group antigen may develop so that she is isoimmunized. With further exposure to Rh-positive blood, the maternal antibodies agglutinate with the RBCs of the fetus that has the antigen and destroy the cells. Hemolytic disease caused by ABO incompatibilities can be present with the first pregnancy. The gender of the first child is not a concern. Blood type is the important consideration. If both parents have type O blood, ABO incompatibility should not be a possibility.
The nurse is planning care for an infant receiving calcium gluconate for treatment of hypocalcemia. Which route of administration should be used?
- A. Oral
- B. Intramuscular
- C. Intravenous
- D. Intraosseous
Correct Answer: C
Rationale: Calcium gluconate is administered intravenously over 10 to 30 minutes or as a continuous infusion. If it is given more rapidly than this, cardiac dysrhythmias and circulatory collapse may occur. Early feedings are indicated, but when the ionized calcium drops below 3.0 to 4.4 mg/dL, intravenous calcium gluconate is necessary. Intramuscular or intraosseous administration is not recommended.