The nurse is assessing an infant with dark skin for jaundice. The nurse plans on assessing this client's
The nurse is assessing an infant with dark skin for jaundice. The nurse plans on assessing this client's
A. hard palate of the mouth.
[47%]
B. lower back and sacrum.
[6%]
C. lower legs right below the knee.
[2%]
D. nail beds.
[44%]
Statistics
Subject/Lesson
Subject
Maternal & Newborn Health
Lesson
Newborn
Client Need
Test Plan
Health Promotion and Maintenance
Related Topic
Ante/Intra/Postpartum and Newborn Care
Item Type
Item Type
Knowledge/Comprehension
Explanation
Choice A is correct. Jaundice is a yellow color of skin and sclerae caused by bilirubin buildup in the baby's blood. In dark-skinned babies, jaundice may not be visible upon skin assessment, even with high blood bilirubin levels. The correct technique when assessing an infant (or an adult) with dark skin for jaundice would be to examine the mucous membranes in the mouth, the hard palate, or the sclera.
Choices B, C, and D are incorrect. Lower back and sacrum, lower legs, and nail beds are not appropriate physical landmarks to assess for jaundice.
Related Videos
4 Key Topics
Newborn Assessment
31.1 Immediate Newborn Evaluation
Jaundice
31.2 Early Newborn Complications
Additional Info
In infants with dark skin, the nurse should assess the color of the palate and mucous membranes of the mouth and the conjunctivae.
- Jaundice begins at the head and moves down the body as the bilirubin level rises.
- The nurse must determine the areas of the body affected by jaundice and document carefully to use for comparison during future assessments.
