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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.
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The nurse is caring for a newborn with Erb palsy. The nurse understands that which reflex is absent with this condition?
- A. Root reflex
- B. Suck reflex
- C. Grasp reflex
- D. Moro reflex
Correct Answer: D
Rationale: Erb palsy (Erb-Duchenne paralysis) is caused by damage to the upper plexus and usually results from stretching or pulling away of the shoulder from the head. The Moro reflex is absent in a newborn with Erb palsy. The root and suck reflex are not affected. A grasp reflex is present in newborns because the finger and wrist movements remain normal.
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.
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.
What is an important nursing intervention for a full-term infant receiving phototherapy?
- A. Observing for signs of dehydration
- B. Using sunscreen to protect the infants skin
- C. Keeping the infant diapered to collect frequent stools
- D. Informing the mother why breastfeeding must be discontinued
Correct Answer: A
Rationale: Dehydration is a potential risk of phototherapy. The nurse monitors hydration status to be alert for the need for more frequent feedings and supplemental fluid administration. Lotions are not used; they may contribute to a frying effect. The infant should be placed nude under the lights and should be repositioned frequently to expose all body surfaces to the lights. Breastfeeding is encouraged. Intermittent phototherapy may be as effective as continuous therapy. The advantage to the mother and father of being able to hold their infant outweighs the concerns related to clearance.
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.