A telephone triage nurse gets a call from a postpartum client concerned about jaundice. The client's newborn is 37 hours old. What data would the nurse need to gather first?
1. Stool characteristics
2. Fluid intake
3. Skin color
4. Bilirubin level
3
Rationale:
1. The nurse does monitor stool characteristics when assessing for jaundice.
2. The nurse does monitor fluid intake when assessing for jaundice.
3. Yellow coloration of the skin and sclera are signs of physiologic jaundice that appear after the first 24 hours postnatally. Inspection of the skin would be the first step in assessing for jaundice. Skin color begins to appear yellow once the serum levels of bilirubin are about 4–6 mg/dL.
4. The nurse does monitor bilirubin level when assessing for jaundice.
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