The nurse is reviewing charts of newborns. Which infant requires immediate intervention?
1. 24-hour-old term male with total bilirubin level of 2.0
2. 3-day-old term bottle-fed female with bilirubin of 11.0
3. 2-week-old post-term breastfed male with bilirubin of 10.0
4. 12-hour-old preterm female exhibiting icterus and lethargy
4
Rationale:
1. Total bilirubin levels under 3.0 are expected in the first 24 hours of life.
2. Physiologic jaundice peaks between days 3 and 5; a total bilirubin level of 11.0 is not treated with phototherapy, regardless of feeding method.
3. Breast milk jaundice peaks at 2–3 weeks of age, and commonly presents with a total bilirubin level of 5.0–10.0.
4. Jaundice is an indication of hyperbilirubinemia, and is not an expected finding in the first day of life. Lethargy can be a sign of kernicterus developing. Preterm infants are more likely to develop jaundice.
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A patient is admitted to the critical care unit with a subdural hematoma. The GCS is used to assess his level of consciousness. In assessing the patient's best motor response, the movement that receives the lowest score is
a. decerebrate posturing. c. withdrawing from pain. b. localizing pain. d. decorticate posturing.
To assess for Trousseau's sign, place a blood pressure cuff on the patient's upper arm and inflate to
a. 10 mm Hg above the patient's diastolic blood pressure for 1 minute. b. the patient's systolic blood pressure for 3–5 minutes. c. 10 mm Hg above the patient's systolic blood pressure for 1–3 minutes. d. 10 mm Hg below the patient's systolic blood pressure for 3–5 minutes.
A nurse colleague states that health care in the hospital is superior to the use of herbal medicine by a Native American. The belief this colleague is expressing would be categorized as:
a. egoism. b. ethnocentrism. c. humanism. d. medicocentrism.
The nurse's technique in assessing for bleeding in a patient who has had a thyroidectomy for bleeding, would be to:
1. check his chest since he is to be positioned in high Fowler's position. 2. turn him side to side to check; he must be kept flat in bed. 3. lift up the neck dressing to see if there is any excessive bleeding. 4. check behind his neck and upper back to detect excess drainage.