The home care nurse is examining a 3-day-old infant. The child's ...

[Chloeellawright]

The home care nurse is examining a 3-day-old infant. The child's skin on the sternum is yellow when blanched with a finger. The parents ask the nurse why jaundice occurs. The best response from the nurse is:
 
  1. The liver of an infant is not fully mature, and doesn't conjugate the bilirubin for excretion.
  2. The infant received too many red blood cells after delivery because the cord was not clamped immediately.
  3. The yellow color of your baby's skin indicates that you are breastfeeding too often.
  4. This is an abnormal finding related to your baby's bowels' not excreting bilirubin as they should.

Question 2

The community nurse is working with a patient at 32 weeks' gestation who has been diagnosed with preeclampsia. Which statement by the patient would indicate that additional information is needed?
 
  1. I should call the doctor if I develop a headache or blurred vision.
  2. Lying on my left side as much as possible is good for the baby.
  3. My urine could become darker and smaller in amount each day.
  4. Pain in the top of my abdomen is a sign my condition is worsening.

[sokh]

Answer to Question 1

1
Rationale 1: Physiologic jaundice is a common occurrence, and peaks on day 3 or 4. It happens in part because of the RBC destruction that infants experience combined with liver immaturity, which leads to less efficient conjugation of bilirubin for excretion.
Rationale 2: The conjugation of bilirubin has nothing to do with cord clamping.
Rationale 3: Bilirubin binds to the proteins in breast milk and formula for excretion through the bowels. Frequent feeding, therefore, will decrease jaundice.
Rationale 4: Bilirubin binds to the proteins in breast milk and formula for excretion through the bowels.

Answer to Question 2

3
Rationale 1: Headache and blurred vision or other visual disturbances are an indication of worsening preeclampsia and should be reported to the physician.
Rationale 2: The left lateral position maximizes uterine and renal blood flow, and therefore is the optimal position for a patient with preeclampsia.
Rationale 3: Oliguria is a complication of preeclampsia caused by renal involvement, and is a sign that the condition is worsening. Oliguria should be reported to the physician.
Rationale 4: Epigastric pain is an indication of liver enlargement, a symptom of worsening preeclampsia, and should be reported to the physician.