MEDizzy - A nurse in the newborn nursery observes a yellowish skin

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Nursing Care of the Newborn

A nurse in the newborn nursery observes a yellowish skin color of an infant whose mother had a cesarean birth. What is the immediate nursing action?

ExplanationB. The neonate’s age is critical because the development of jaundice before 24 to 48 hours after birth may indicate a blood dyscrasia (pathologic jaundice, hyperbilirubinemia), requiring immediate investigation. Jaundice occurring between 48 and 72 hours after birth (physiologic jaundice) is a consequence of the expected breakdown of fetal red cells and immaturity of the liver. A. Unless the jaundice was pathologic (occurring in the first 24 hours of life), this is not necessary. C. First, the age of the neonate must be ascertained to determine if this is physiologic or pathologic jaundice; then the nurse should obtain a sample of heel blood to determine the serum bilirubin level. D. Bilirubin studies should be done first to determine whether the serum level warrants phototherapy. This therapy requires a health care provider’s order