A home care nurse is visiting a 5-day-old male infant for a scheduled follow-up appointment to ensure that he is responding to home phototherapy for treatment of jaundice
After completing a thorough assessment and obtaining a history from the parents, the nurse recognizes that this infant is in the first phase of encephalopathy when he exhibits: 1. A high-pitched cry when touched.
2. Severe muscle spasms.
3. Fever and seizures.
4. Hypotonia, lethargy, and a poor suck when feeding.
4
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1. A high-pitched cry occurs in later phases of the encephalopathy.
2. Muscle spasms are not present with this diagnosis.
3. Fevers are rare in neonates with encephalopathy. The seizures can occur if the levels continue to climb.
4. Hypotonia, lethargy, and poor feedings are the first symptoms to occur in the first phase of encephalopathy caused by jaundice.
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