Health Promotion and Maintenance
52. A 24-hour-old neonate is icteric with a serum bilirubin level of 14 mg/100 mL. The mother's blood type is O+; the blood type of the baby is B and has a positive direct Coombs' test. The infant is being breastfed. Which measure should a nurse include in the neonate's plan of care?
. No special measures are necessary; newborns normally get a little jaundiced.
. Tell the mother to stop breastfeeding and give formula to the baby instead.
. Place the infant under the bililights and prepare for an exchange transfusion.
. Encourage the mother to increase the frequency of breastfeeding sessions.
Test-Taking Tip
The risk factor for this client is the ABO incompatibility. Eliminate the answer that refers to the level being normal, or the answer that deals with jaundice related to breastfeeding.
Content Area: Child Health, Newborn; Integrated Process: Nursing Process, Implementation; Cognitive Level: Analysis; Client Need/Subneed: Physiological Integrity/Physiological Adaptation/Alterations in Body Systems
Health Promotion and Maintenance
.
Answer 1 is incorrect because bilirubin levels in excess of 12 mg/100 mL at 24 hours of age may indicate the presence of a pathological process. This client's jaundice is most likely due to an ABO incompatibility. Answer 2 is incorrect because breastfeeding jaundice occurs around the third day of age. Encouraging early and frequent feedings at the breast lowers neonatal bilirubin levels. This client developed high serum bilirubin at 24 hours of age. Answer 3 is incorrect because bililight therapy requires an order from the physician. Exchange transfusions for ABO incompatibilities are seldom necessary.Answer 4 is correct because early and frequent breastfeeding tends to lower serum bilirubin levels and avoids dehydration that increases the serum bilirubin level.