Edapt: Hyperbilirubinemia
Review the client's electronic health record (EHR) then highlight the assessment findings on each tab that require immediate follow up.
36 2/7 gestation 8lbs 12 oz Blood Type O+ Cephalohematoma noted on the right-posterior aspect of the head Sleepy at breast Bilirubin 6.1 Preterm delivery large for gestational age the cephalohematoma noted on the right-posterior aspect of the head, sleepy at the breast, maternal blood type O+, and a bilirubin level of 6.1 mg/dL at 12 hours after birth are all signs that require follow up. The APGAR scores show a newborn that is adapting well to extrauterine life and is oxygenating. Newborn blood sugars are stable and newborn voids are appropriate for the age/hours old.
A newborn being discharged home has an elevated bilirubin level and a phototherapy blanket has been prescribed for home therapy. The nurse should instruct the parents to put clothes on the newborn (before or after) they apply the phototherapy blanket and that the feedings should be (maintained or stopped) during the phototherapy treatments.
After Maintained --- The phototherapy blanket should be applied directly to the newborn's back or abdomen. Clothing or baby blankets should not be used between the phototherapy blanket and the newborn. The newborn can wear clothing if the blanket is the first layer against the skin. It is safe to continue feeding the newborn during the phototherapy blanket treatment.
Which newborns are most at risk for hyperbilirubinemia? Select all that apply. An newborn born at 32 weeks A bottle feeding newborn A newborn with facial bruising from delivery A 2-day-old newborn who has stooled once in 24 hours A newborn with Coombs positive blood
An newborn born at 32 weeks A newborn with facial bruising from delivery A newborn with Coombs positive blood --------- Preterm newborns, newborns bruised from delivery, and newborns with a positive Coombs test are at higher risk for hyperbilirubinemia. A newborn should have a bowel movement for every day of life, so a two-day-old that has already had one bowel movement (BM) is not a concern at this time. A bottle-feeding newborn typically gets enough intake to allow for bowel movements and excretion of excess red blood cells (RBCs) that could cause jaundice.
The nurse is working in a postpartum unit caring for 4 mothers and 5 newborns. One newborn is 24-hours-of-age and has just had their bilirubin checked, with a result of 9 mg/dL. According to this chart, the result is considered
High Risk
Which findings, noted at 21:30 in both the Nurses' Notes and Laboratory Results, indicate that the newborn's condition Improved No Change Declined Bilirubin level Temperature Blood glucose Breastfeeding
Improved Bilirubin Lvl breastfeeding No Change Blood glucose Declined Temperature The temperature has increased indicating a decline in the condition and that the phototherapy may be causing overheating. Blood glucose remained at a normal level, indicating no change in the condition. The bilirubin level has decreased significantly indicating the risk level has declined from high intermediate to low intermediate indicating an improvement in the newborn's condition. Breastfeeding has improved.
Phototherapy was prescribed by the healthcare provider. Click to specify if each potential nursing intervention is indicated nonessential contraindicated. Check the newborn's temperature frequently. Cover the newborn's eyes with an eye mask. Dress the newborn in a diaper and a shirt. Bathe the newborn.
Indicated Check the newborn's temperature frequently. Cover the newborn's eyes with an eye mask. Nonessential Bathe newborn Contraindicted Dress the newborn in a diaper and a shirt ------- The eyes should remain covered at all times during phototherapy. The newborn is at risk of overheating under phototherapy, so assessing the temperature regularly will allow for early intervention to prevent overheating. Maximum skin exposure during phototherapy supports decreasing the bilirubin levels. The newborn should only wear a diaper. A bath can be provided, but it is nonessential.
Based on the information in the client record, the nurse should closely monitor the newborn for signs of which potential complications? Select all that apply. Respiratory distress Infection Dehydration Hyperbilirubinemia Hypoglycemia
Infection Dehydration Hyperbilirubinemia Hypoglycemia ------- The prolonged rupture of membranes (20 hours) and prematurity both increase the risk for infection and the nurse should take measures to prevent infection and monitor for signs. Although the blood sugar is currently normal, newborns with mothers who have diabetes and who are large for gestational age are at increased risk for hypoglycemia, so the nurse should continue to closely monitor the newborn for signs of hypoglycemia. Although the voiding pattern is normal at this time, poor feedings may lead to dehydration, so the nurse should also closely monitor the newborn's intake and output. There is no indication of respiratory distress.
A nurse is managing a high-risk bilirubin level in a newborn who is receiving phototherapy. Which interventions should be part of the plan of care? Select all that apply. Check the newborn's temperature every 6 hours. Maintain eye protection during phototherapy. Remove all clothing except for a diaper. Ensure the newborn is receiving frequent feedings. Stop breastfeeding and switch to bottle feeding.
Maintain eye protection during phototherapy. Remove all clothing except for a diaper. Ensure the newborn is receiving frequent feedings. ---- Feeding the newborn at a regular frequency is key and formula may be used as a supplement if there is not adequate breast milk production. Breastfeeding does not need to be stopped because of phototherapy, but the nurse may need to offer extra support to ensure the newborn is receiving adequate nutrition. Eye protection is always needed when the newborn is under phototherapy lights. In order to expose as much skin as possible to the phototherapy light, newborns should be placed under the lights wearing only a diaper. The temperature must be checked every 2-4 hours or per agency policy, because temperature instability increases with phototherapy.
The nurse is reviewing two newborn charts. One newborn had an elevated bilirubin level at 3 days postpartum, which indicates that the newborn has physiological jaundice. The other newborn developed jaundice within the first 5 hours, which indicates that this newborn has pathological jaundice.
Physiological Pathological
A client is being discharged home with a 2-day-old newborn and is receiving education on hyperbilirubinemia. For which newborn symptoms should the client be instructed to notify the healthcare provider? Select all that apply. Poor feeding High-pitched cry Difficult to arouse Reduced output Breastfeeding 10 times a day Limp extremities
Poor feeding High-pitched cry Difficult to arouse Reduced output Limp extremities ---------- Untreated hyperbilirubinemia can lead to kernicterus. Educating parents for symptoms to report is important in preventing kernicterus. Symptoms that should be reported include a newborn who is difficult to wake up and appears limp and floppy. The healthcare provider should also be notified if the newborn has difficulty feeding and has reduced output. Newborns frequently cry, but when the cry is high-pitched, it may be a sign of a neurological issue and should be reported. Breastfeeding 10 times a day is not concerning.
Which two nursing actions will enhance the newborn's response to phototherapy? Discontinue breastfeeding Check placement of eye patches every hour Remove all clothing except diaper Turn newborn frequently Check axillary temperature every 2-4 hours
Remove all clothing except diaper Turn newborn frequently ------- Exposing as much skin as possible and turning the newborn frequently to expose all areas of the skin to the bili lights will both enhance the newborn's response to phototherapy. Checking the placement of the eye patches is important for safety and checking the temperature frequently will prevent overheating, but neither will enhance the newborn's response to therapy. It is not recommended that breastfeeding is discontinued. The newborn can be removed from the phototherapy for feedings.
A nurse is completing an assessment of a newborn receiving overhead phototherapy initiated 6 hours ago. Which findings should lead to immediate action by the nurse? Select all that apply. The newborn is wearing a shirt. The newborn temperature is 99.6F (37.6C). The newborn's diaper is filled with loose, green stools. The newborn's eyes are covered with an eye shield. The skin blanches yellow on the nose and chest.
The newborn is wearing a shirt. The newborn temperature is 99.6F (37.6C). The newborn's diaper is filled with loose, green stools. -------- The skin should be exposed as much as possible during phototherapy, so the newborn should not be wearing a shirt. A newborn temperature of 99.6F is just above the normal range. The nurse should make sure that the phototherapy lights are not causing overheating. Although, loose, green stools are expected with phototherapy treatment, the nurse should immediately change the diaper to prevent skin breakdown. Eye protection is required, so having an eye shield is appropriate and supports safety for the newborn. The skin blanching yellow on the nose and chest is expected after only 6 hours of phototherapy.
A newborn with jaundice is being discharged with an in-home phototherapy blanket. What information should the nurse provide the parents before discharge? Select all that apply. Eye covering must be used during the treatment . There may be an increase in bowel movements that have a greenish tinge. The phototherapy treatment will continue for two months. The newborn can be fed and held without interrupting treatment. Dress the newborn and then swaddle with a phototherapy blanket.
There may be an increase in bowel movements that have a greenish tinge. The newborn can be fed and held without interrupting treatment. ------- Newborns receiving phototherapy treatment may have frequent and loose bowel movements that are sometimes greenish in color. This is normal since this is the way the body removes the bilirubin. This will be temporary and should stop when the treatment is completed. The newborn should be swaddled with the blanket against the skin, with no clothing underneath. Treatment usually lasts days, not months, and discontinuation will be determined based on reduced bilirubin levels. No eye coverings are needed with a phototherapy blanket and a newborn can be held and fed without interrupting the treatment.
A nurse is assessing a newborn for the presence of jaundice. Which of the following assessments may be used? Select all that apply. Visualizing the color of the palate. Checking the level of irradiance. Blanching the skin. Obtaining a complete blood count (CBC). Using a transcutaneous bilirubinometer.
Visualizing the color of the palate. Blanching the skin. Using a transcutaneous bilirubinometer. ------- Blanching the skin over a bony prominence and looking at the color before blood returns will reveal yellowing of the skin. In newborns with dark skin, assessing the color of the palate or mucus membranes of the mouth can also be used to assess for jaundice. Transcutaneous bilirubinometers are non-invasive devices that will record bilirubin levels when placed against the newborn's skin. CBC does not include a bilirubin level. Checking the level of irradiance is related to ensuring the phototherapy machine is functioning properly, and not an assessment of jaundice.
Based on the information in the client record, the highest priority concern for the newborn is (infection or hypoglycemia or hyperbilirubinemia or dehydration).
hyperbilirubinemia ---- The highest priority concern is the bilirubin level of 6.1 mg/dL at 12 hours of age, which places the newborn in the high intermediate risk zone. Infection, hypoglycemia, and dehydration are all potential complications that may occur due to maternal history, newborn size, prematurity, and poor feeding.
The nurse is discussing jaundice with a concerned mother of a newborn. The nurse knows that with high levels of bilirubin, the primary concern is (transient tachypnea or kernicterus)
kernicterus. ------- When high bilirubin levels go untreated for too long, it can cause a condition called kernicterus. Kernicterus is a type of brain damage that can result from high levels of bilirubin in a newborn's blood. The newborn may become more lethargic and difficult to awaken and thus has a lower respiratory rate rather than tachypnea.
