The nurse is caring for a newborn born to a client who ...

[clmills979]

The nurse is caring for a newborn born to a client who experienced abruptio placentae. Which assessment findings suggest that the infant is experiencing anemia? Select all that apply.
 
  1. Pallor
  2. Tachypnea
  3. Tachycardia
  4. Elevated blood pressure
  5. Capillary refill 6 seconds

Question 2

The mother of a 4-day-old infant is concerned that the infant's skin tone is yellow and asks if the baby should be hospitalized. What should the nurse consider as being the cause of this infant's skin color change?
 
  1. Pathologic jaundice
  2. Physiologic jaundice
  3. Acute bilirubin encephalopathy
  4. Hemolytic disease of the newborn

[TDubDCFL]

Answer to Question 1

1, 2, 3, 5
Explanation:
1. Pallor is a manifestation of anemia in a newborn.
2. Tachypnea is a manifestation of anemia that is compromised in a newborn.
3. Tachycardia is a manifestation of anemia in a newborn.
4. Low blood pressure is a manifestation of anemia in a newborn.
5. Capillary refill greater than 3 seconds is an indication of anemia in a newborn.

Answer to Question 2

3
Explanation:
1. Pathologic jaundice usually appears before 24 hours of life and is the result of a more serious underlying condition.
2. Infants can develop physiologic jaundice 4 to 5 days after birth as a result of a shortened red blood cell life span, slow uptake of bilirubin by the liver, a lack of intestinal bacteria, or poorly established hydration from initial breastfeeding.
3. Acute bilirubin encephalopathy, or kernicterus, is a serious medical condition resulting from very high bilirubin levels as a result of pathologic jaundice. This is unlikely to occur with physiologic jaundice.
4. Hemolytic disease of the newborn occurs as a result of blood incompatibility between the mother and infant and is usually diagnosed shortly after birth.