Page 857 - Saunders Comprehensive Review For NCLEX-RN

is provided. After treatment, the newborn is monitored for signs of
hyperbilirubinemia because rebound elevations can occur after therapy is
discontinued.
Test-Taking Strategy: Focus on the subject, phototherapy. Recalling that adverse
effects from treatment, such as eye damage, dehydration, or sensory deprivation, can
occur will assist in determining the correct interventions.
Level of Cognitive Ability: Analyzing
Client Needs: Safe and Effective Care Environment
Integrated Process: Nursing Process—Implementation
Content Area: Maternity: Newborn
Health Problem: Newborn: Hyperbilirubinemia
Priority Concepts: Cellular Regulation; Safety
Reference: McKinney et al. (2018), pp. 647-648.

280. Answer: 2

Rationale: An infant born to a mother infected with HIV must be cared for with
strict attention to standard precautions. This prevents the transmission of HIV from
the newborn, if infected, to others and prevents transmission of other infectious
agents to the possibly immunocompromised newborn. Options 1 and 3 are not
associated specifically with the care of a potentially HIV-infected newborn. Mothers
infected with HIV should not breast-feed.
Test-Taking Strategy: Eliminate options 1 and 3 first because they are comparable
or alike and are not associated specifically with the care of a potentially HIV-
infected newborn. Recalling that HIV-infected mothers should not breast-feed will
direct you to the correct option.
Level of Cognitive Ability: Creating
Client Needs: Safe and Effective Care Environment
Integrated Process: Nursing Process—Planning
Content Area: Maternity: Newborn
Health Problem: Newborn: Newborn of a Mother with HIV/AIDS
Priority Concepts: Infection; Safety
Reference: McKinney et al. (2018), pp. 940-941.

281. Answer: 2

Rationale: The newborn of a diabetic mother is at risk for hypoglycemia, so
maintaining safety because of low blood glucose levels would be a priority. The
newborn would also be at risk for hyperbilirubinemia, respiratory distress,
hypocalcemia, and congenital anomalies. Developmental delays, choking, and an
elevated body temperature are not expected problems.
Test-Taking Strategy: Note the strategic word, priority. Read each option
thoroughly and eliminate options 1, 3, and 4 because they are comparable or alike in
that newborns of diabetic mothers are not at risk for these problems. Also, note the
relationship of the words diabetes mellitus in the question and the word glucose in the
correct option.
Level of Cognitive Ability: Analyzing

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