Author Question: The nurse is assessing a newborn delivered 24 hours ago for jaundice. What is the best way to ... (Read 55 times)

penguins · **on:** Jun 28, 2018

The nurse is assessing a newborn delivered 24 hours ago for jaundice. What is the best way to evaluate for this finding?

a. Depress the tip of the nose.
b. Stroke the outer aspect of the foot.
c. Place a finger in the palm of the hand.
d. Rotate the hips in an upward and outward direction.

Question 2

An infant at term was born at 0105, or 1:05 AM. The nurse is developing a plan of care for the newborn. During which time range will the nurse plan on performing the assessment to determine a Ballard score?

a. 0115-0130
b. 0200-0600
c. 1400-1800
d. 2000-2300

chevyboi1976 · **Reply #1 on:** Jun 28, 2018

Answer to Question 1

ANS: A
The nurse assesses for jaundice at least every 8 to 12 hours and is particularly watchful when infants are at increased risk for hyperbilirubinemia. Jaundice is identified by pressing the infant's skin over a firm surface, such as the end of the nose or the sternum. The skin blanches as the blood is pressed out of the tissues, making it easier to see the yellow color that remains. Jaundice is more obvious when the nurse assesses in natural light. Jaundice begins at the head and moves down the body, and the areas of the body involved should be documented. Jaundice becomes visible when the bilirubin level is greater than 5 mg/dL. The Babinski reflex is assessed by stroking the outer aspect of the foot. The grasp reflex is determined by placing a finger in the newborn's palm. The Barlow and Ortolani tests are methods of assessing for hip instability in the newborn period. Both legs should abduct equally in normal infants. Abducting the affected hip may be difficult. A hip click may be felt or heard but is usually normal and is different from the clunk of hip dysplasia when the femoral head moves in the hip socket.

Answer to Question 2

ANS: B
The new Ballard score is often used to assess gestational age based on neuromuscular and physical characteristics. It is designed to assess gestational age from 20 to 44 weeks and provides accurate information within 2 weeks. It is most accurate when performed within 12 hours of birth.