A nurse is caring for a newborn who was born at 37 weeks of gestation and is 12 hours old.
Exhibits
Complete the diagram by dragging from the choices below to specify what condition the newborn is most likely experiencing, two actions the nurse should take to address that condition, and two parameters the nurse should monitor to assess the newborn’s progress.
The correct answer and Explanation is :
To address the scenario described, the newborn who was born at 37 weeks of gestation is most likely experiencing neonatal jaundice. Here’s a detailed explanation of the condition, the actions the nurse should take, and the parameters to monitor:
Condition:
Neonatal Jaundice: This condition is common in newborns, particularly those born preterm. It is characterized by a yellowish tint to the skin and sclera (the white part of the eyes) due to an excess of bilirubin in the blood. At 37 weeks of gestation, the newborn’s liver may not be fully mature, which can impair its ability to process bilirubin effectively.
Actions the Nurse Should Take:
- Initiate Phototherapy: Phototherapy involves exposing the newborn to a special type of light that helps break down bilirubin in the skin. This is a common and effective treatment for neonatal jaundice and helps prevent bilirubin from reaching toxic levels.
- Ensure Adequate Hydration and Feeding: Adequate feeding helps maintain hydration and promotes the elimination of bilirubin through the stool. The nurse should ensure the newborn is feeding well, whether breastfeeding or formula feeding, to support this process.
Parameters to Monitor:
- Bilirubin Levels: Regular monitoring of serum bilirubin levels is crucial to assess the severity of jaundice and determine the effectiveness of phototherapy. This helps in making informed decisions about the continuation or adjustment of treatment.
- Skin Color and Vital Signs: Continuous assessment of the newborn’s skin color is important to monitor the progress of jaundice. Additionally, monitoring vital signs like temperature and heart rate ensures the newborn is stable and responds well to the treatment.
Explanation:
Neonatal jaundice is particularly common in preterm infants due to the immaturity of the liver. The liver enzyme systems responsible for processing bilirubin are not fully developed, leading to an accumulation of bilirubin. Phototherapy is a non-invasive treatment that helps convert bilirubin into a form that can be more easily excreted. Adequate feeding supports the baby’s digestive system and aids in the excretion of bilirubin. Monitoring bilirubin levels and the newborn’s skin color helps track the effectiveness of treatment and detect any potential complications early.
By taking these actions and monitoring these parameters, the nurse plays a crucial role in managing and improving the newborn’s condition.