A telephone triage nurse gets a call from a postpartum client who is concerned about jaundice in a 37-hour-old newborn. What information should the nurse gather first?
1. Skin color
2. Fluid intake
3. Bilirubin level
4. Stool characteristics
1
Explanation:
1. Yellow coloration of the skin and sclerae is a sign of physiologic jaundice that appears after the first 24 hours postnatally. Inspection of the skin would be the first step in assessing for jaundice.
2. Inadequate fluid intake can predispose an infant toward becoming jaundiced and is best determined by the number of wet diapers per day.
3. Skin color begins to appear yellow once the serum levels of bilirubin are about 4 to 6 mg/dL.
4. The stool characteristic of yellow-brown coloration indicates excretion of bilirubin.
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a. Diarrhea b. Constipation c. Nausea d. Abdominal cramping
The nurse who is to administer 2.5 mL of intramuscular pain medication to an adult client notes that the previous injection was administered in the right ventrogluteal site. In which site should the nurse plan to administer this injection?
A) The rectus femoris B) The same site C) The deltoid D) The left ventrogluteal
The best term for breath sounds created by air moving through large lung airways is
a. Bronchovesicular. b. Rhonchi. c. Bronchial. d. Vesicular.
A fetal weight is estimated at 4490 grams in a gravida 1 at 38 weeks' gestation. Counseling should occur before labor regarding the:
1. Mother's undiagnosed diabetes. 2. Likelihood of a cesarean delivery. 3. Effectiveness of epidural anesthesia with a large fetus. 4. Need for early delivery.