As the newborn nursery nurse, you are assessing your patients. Which assessment warrants further investigation?

Correct Answer: B

Rationale: The correct answer is B: Periodic episodes of grunting during expiration. This warrants further investigation as grunting during expiration is a sign of respiratory distress in newborns, indicating potential respiratory compromise. It can be a sign of underlying lung pathology or inadequate oxygenation. It is important to assess and address this promptly to prevent further deterioration. Incorrect choices: A: Irregular patterns of breathing with periods of apnea lasting 5 seconds - While apnea can be concerning, it is common in newborns. This alone may not warrant immediate further investigation. C: Breathing at a rate of 45 breaths per minute - A respiratory rate of 45 breaths per minute can be within normal range for a newborn. It may not be abnormal unless accompanied by other signs of distress. D: Mild sternal retractions - Sternal retractions can be a sign of increased work of breathing, but mild retractions alone may not be as concerning as grunting during expiration.

Correct Answer: D

Rationale: The correct answer is D because elevated bilirubin levels in newborns indicate jaundice, which can lead to complications if not treated promptly. Phototherapy helps break down bilirubin and is the first-line treatment for neonatal jaundice. Applying phototherapy as per hospital protocol is essential to decrease bilirubin levels. Notifying the physician is also crucial for ongoing monitoring and management. Choice A (Place the patient NPO and notify a physician) is incorrect because NPO status is not necessary for managing neonatal jaundice, and phototherapy is the primary intervention. Choice B (Weigh the patient to see if weight loss has occurred) is incorrect because weight loss is not directly related to elevated bilirubin levels in newborns. Choice C (Take the newborn’s vital signs and report to the physician) is incorrect because while vital signs are important, the immediate intervention for elevated bilirubin levels is phototherapy to prevent complications.

Correct Answer: D

Rationale: The correct answer is D: Review orders for the timing of next BG reading. This is the correct action because the nurse should follow the protocol and guidelines set by the healthcare provider regarding the frequency and timing of blood glucose monitoring in newborns. By reviewing the orders, the nurse ensures that the newborn's blood glucose levels are monitored appropriately and at the right intervals. This helps in maintaining the newborn's health and identifying any potential issues promptly. Other choices are incorrect: A: Notify the physician immediately that the BG readings on this newborn are low - Premature action without assessing the situation or following protocol. B: Immediately give the newborn glucose water - Inappropriate and potentially harmful intervention without proper evaluation. C: Confirm the readings with the laboratory - Unnecessary step as the nurse can follow the established protocol without involving the laboratory unnecessarily.

Correct Answer: B

Rationale: The correct answer is B because a 5-day-old term newborn with bilirubin levels of 13 mg/dL and exclusively breastfeeding is at higher risk for developing physiological jaundice. Breastfeeding jaundice occurs due to inadequate milk intake leading to limited bowel movements, causing reabsorption of bilirubin. The other choices are incorrect because: A has normal bilirubin levels and is bottle feeding, which is less likely to cause jaundice. C is a premature baby with low bilirubin levels and meconium passage. D is a term newborn with high bilirubin levels but is breastfed frequently, reducing the risk of jaundice.

Correct Answer: D

Rationale: The correct answer is D: Cord blood gas. When the mother has Rh type O blood and the newborn's Apgar score is low, it indicates potential oxygenation issues during birth. Cord blood gas analysis is crucial to assess the newborn's oxygenation status and acid-base balance. A low Apgar score suggests the need to evaluate the newborn's respiratory and metabolic functions, which can be done through cord blood gas analysis. A: Cardiac enzymes - Not relevant in this scenario as the focus is on oxygenation and respiratory function, not cardiac issues. B: Blood glucose - Not directly related to the situation described, as low Apgar score and Rh blood type are more indicative of oxygenation and potential Rh incompatibility. C: Electrolyte panel - While electrolyte imbalance is important, cord blood gas analysis provides more immediate information on oxygenation and acid-base balance, which are crucial in low Apgar score situations.