31. A nurse assessing for jaundice in a dark-skinned newborn. : 1361477

31. A nurse assessing for jaundice in a dark-skinned newborn. : 1361477.


31. A nurse is assessing for jaundice in a dark-skinned newborn. Where is the best place to assess for jaundice in this newborn?

a. Buttocks

b. Tip of nose and sclera

c. Sclera, conjunctiva, and oral mucosa

d. Palms of hands and soles of feet

32. A blood sample for measurement of bilirubin is required from a newborn receiving phototherapy. In what environment should this blood sample be drawn?

a. While phototherapy lights are turned off

b. While newborn remains under phototherapy lights

c. When newborn is covered with a blanket

d. When newborn has been off phototherapy for 30 to 60 minutes

33. The nurse is preparing a parent of a newborn for home phototherapy. Which statement made by the parent would indicate a need for further teaching?

a. “I should change the baby’s position many times during the day.”

b. “I can dress the baby in lightweight clothing while under phototherapy.”

c. “I should be sure that the baby’s eyelids are closed before applying patches.”

d. “I can take the patches off the baby during feedings and other caregiving activities.”

34. The nurse is caring for a newborn with hyperbilirubinemia who is receiving phototherapy. Which is an appropriate nursing intervention for this newborn?

a. Apply lotion as prescribed to moisturize skin.

b. Maintain nothing-by-mouth (NPO) status to prevent nausea and vomiting.

c. Monitor temperature to prevent hypothermia or hyperthermia.

d. Keep eye patches on for at least 8 to 12 of every 24 hours.

35. Hemolytic disease is suspected in a mother’s second newborn. Which factor is important in understanding how this could develop?

a. The mother’s first child was Rh positive.

b. The mother is Rh positive.

c. Both parents have type O blood.

d. RhIG (RhoGAM) was given to the mother during her first pregnancy.

36. When should the nurse expect jaundice to be present in a newborn with hemolytic disease?

a. At birth

b. During first 24 hours after birth

c. 24 to 48 hours after birth

d. 48 to 72 hours after birth

37. To prevent Rh isoimmunization, RhIG (RhoGAM) is administered to all:

a. Rh-negative women who deliver an Rh-positive newborn.

b. Rh-positive women who deliver an Rh-negative newborn.

c. Rh-negative newborns whose mothers are Rh positive.

d. Rh-positive fathers before conception of second newborn when first newborn was Rh positive.

38. The nurse is caring for a newborn receiving an exchange transfusion for hemolytic disease. Assessment of the newborn reveals slight respiratory distress and tachycardia. Which should the nurse’s first action be?

a. Notify practitioner.

b. Stop the transfusion.

c. Administer calcium gluconate.

d. Monitor vital signs electronically.

39. Which is the primary treatment for hypoglycemia in newborns with feeding intolerance?

a. Oral glucose feedings

b. Intravenous (IV) infusion of glucose

c. Short-term insulin therapy

d. Feedings (formula or breast milk) at least every 2 hours

40. Which is the most appropriate nursing intervention for the newborn who is jittery and twitching and has a high-pitched cry?

a. Monitor blood pressure closely.

b. Obtain urine sample to detect glycosuria.

c. Obtain serum glucose and serum calcium levels.

d. Administer oral glucose or, if newborn refuses to suck, IV dextrose.



31. A nurse assessing for jaundice in a dark-skinned newborn. : 1361477

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