Low Risk Neonatal Nursing Examination – Rationale Samples

Question

To differentiate peripheral from central cyanosis in a 12 hour old neonate, the best assessment to initiate is to

  • check the capillary refill
  • observe skin color when the infant is crying
  • warm the infant and observe for improvement in color

Rationale

It is essential to differentiate between central and peripheral cyanosis in the neonate because central cyanosis can portend major cardiac or respiratory disease. Peripheral cyanosis generally occurs in the neonate and is transient during the first 48 hours of life. One way to differentiate it is to warm the infant and see if the cyanosis improves. If it does, this is not central cyanosis. Location of cyanosis is also a cue. In peripheral cyanosis, it usually occurs in the extremities and central cyanosis is more generalized. A crying infant can cause transient cyanosis so it is best to observe the infant when it is quiet. Capillary refill is usually done to assess peripheral perfusion.

Question

A neonate is receiving phototherapy but bilirubin levels continue to rise rapidly. An anticipated intervention would be to

  • add an additional bank of phototherapy lights
  • obtain an order for phenobarbital
  • prepare the neonate for an exchange transfusion

Rationale

Rapidly rising bilirubin levels despite phototherapy is a serious problem. These neonates are candidates for exchange transfusion to prevent kernicterus and to protect the infant's central nervous system status. Phototherapy is limited in addressing rapidly rising level so adding additional banks of light will not greatly improve the situation. Phenobarbital apparently accelerates bilirubin excretion by increasing conjugation but studies have shown it provides no greater effect than phototherapy. It would, therefore, not be a viable intervention in this case.