A term infant is 22 hours old, has a total serum bilirubin level of 13 mg/dL, and has visible jaundice. What action by the nurse is most appropriate?
A.
Assure the parents that this is temporary.
B.
Document the findings in the infant's chart.
C.
Have the mother switch to bottle feeding.
D.
Review the chart for history of a traumatic birth.
ANS: D
Jaundice that appears within the first 24 hours of life is considered pathological. Causes can include events that lead to excessive breakdown of RBCs, leading to increased bilirubin levels, such as polycythemia, traumatic birth, infection, metabolic disorders, and Rh incompatibility. The diagnosis is made when total serum bilirubin levels rise higher than 12.9 mg/dL in term infants and 15 mg/dL in preterm infants. The nurse should review the chart for evidence of a traumatic birth. The other actions are not warranted.
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