# A newborn with erythroblastosis fetalis is admitted to the neonatal intensive care unit. The infant's bilirubin level is 18 mg/dL at 12 hours of age, and phototherapy has been initiated. Which nursing intervention is the highest priority for this infant?

> source: MyMerci (mymerci.kr)  
> url: https://mymerci.kr/pages/nclex_q.php?qn_id=543282  
> language: ko  
> subject: Maternal Newborn Health

## 문제

A newborn with erythroblastosis fetalis is admitted to the neonatal intensive care unit. The infant's bilirubin level is 18 mg/dL at 12 hours of age, and phototherapy has been initiated. Which nursing intervention is the highest priority for this infant?

## 보기

1. Maintain strict intake and output monitoring every 2 hours
2. Position the infant prone to maximize phototherapy exposure
3. Monitor for signs of kernicterus and neurological changes **✔ 정답**
4. Encourage frequent breastfeeding to promote bilirubin elimination

**정답: 3**

## 해설

Monitoring for kernicterus is the highest priority because severe hyperbilirubinemia can cause permanent neurological damage. Other interventions are important but do not address the most critical complication.

## 심화 해설

Understanding the Priority

The highest priority for a newborn with erythroblastosis fetalis and a markedly elevated bilirubin level of 18 mg/dL at 12 hours of age is to monitor for signs of kernicterus and neurological changes. The primary pathological threat in hemolytic disease of the newborn (HDN) is the rapid rise in unconjugated bilirubin, which can cross the immature blood-brain barrier and deposit in the basal ganglia and brainstem nuclei, causing irreversible neurological damage known as kernicterus or bilirubin encephalopathy.

Pathophysiology and Clinical Rationale

The provided source explains that the pathophysiology of HDN begins with maternal antibodies attacking fetal red blood cells following alloimmunization. This immune-mediated hemolysis causes a rapid and massive release of hemoglobin, which is catabolized into bilirubin. A level of 18 mg/dL at only 12 hours of life is a critical finding, far exceeding the threshold for initiating urgent interventions. At this level, the infant's primary risk is not just jaundice but acute bilirubin encephalopathy, which can progress to permanent, devastating sequelae if not detected immediately. Therefore, vigilant neurological assessment is the nurse's most direct role in preventing permanent injury. The nurse must systematically assess for early, subtle signs such as lethargy, poor feeding, high-pitched cry, hypotonia, and a poor or absent Moro reflex, which can progress to opisthotonos, seizures, and fever.

Analysis of Other Options

While the other interventions are important aspects of care, they do not address the most immediate, life-altering threat.

- Option 1 (I&O monitoring): Monitoring fluid balance is essential because phototherapy increases insensible water loss, and adequate hydration supports renal excretion of photoisomers. However, this is a supportive measure to prevent dehydration, not the primary intervention to prevent neurological devastation.

- Option 2 (Prone positioning): Positioning the infant supine is the standard of care to reduce the risk of sudden infant death syndrome (SIDS). To maximize exposure during phototherapy, the infant is kept nude except for a diaper and eye shields, and the position is changed frequently, but prone positioning is specifically contraindicated for unsupervised sleep.

- Option 4 (Frequent breastfeeding): Encouraging frequent feeding promotes gastrointestinal motility and can help excrete bilirubin via stool. However, in the context of severe hemolysis with a bilirubin level of 18 mg/dL, the infant may be too lethargic to feed effectively, and enteral intake alone cannot reverse the rapid hemolysis. The immediate threat of kernicterus from the already circulating high bilirubin load takes absolute precedence over promoting elimination through feeding. The source notes that with early diagnosis, the condition can be fairly well managed with fewer complications, and this management hinges on preventing the acute neurotoxicity that monitoring for kernicterus represents.

## 임상 시나리오

Kernicterus Monitoring in Severe HyperbilirubinemiaEarly Detection of Acute Bilirubin Encephalopathy
A bilirubin level of 18 mg/dL at 12 hours of life is a critical emergency. The nurse's highest priority is to monitor for kernicterus by assessing neurological status every 2 to 4 hours during phototherapy.

Early signs of bilirubin neurotoxicity include lethargy, hypotonia, poor feeding, and a high-pitched cry. Late, irreversible signs include opisthotonos, seizures, and fever.

CautionNever place an infant in the prone position for phototherapy. The safe standard is supine to reduce the risk of SIDS, while ensuring maximal skin exposure by using only a diaper and eye shields.

## 핵심 개념

- **Kernicterus** — A preventable, irreversible neurological syndrome caused by the deposition of unconjugated bilirubin in the basal ganglia and brainstem nuclei, leading to permanent brain damage.
- **Erythroblastosis Fetalis** — A severe hemolytic disease of the newborn resulting from maternal alloimmunization, where maternal antibodies cross the placenta and destroy fetal red blood cells.
- **Unconjugated Bilirubin** — A fat-soluble, indirect form of bilirubin that can cross the immature blood-brain barrier and is neurotoxic at high levels.
- **Phototherapy** — A treatment using specific wavelengths of light to convert unconjugated bilirubin into water-soluble isomers that can be excreted without liver conjugation.

## 같은 주제 문제

- [A 2-day-old newborn diagnosed with erythroblastosis fetalis has a bilirubin level of 18 mg…](https://mymerci.kr/pages/nclex_q.php?qn_id=543281)
- [A 2-day-old infant diagnosed with severe erythroblastosis fetalis is admitted to the neona…](https://mymerci.kr/pages/nclex_q.php?qn_id=543283)
- [A 3-day-old newborn diagnosed with erythroblastosis fetalis is receiving phototherapy and …](https://mymerci.kr/pages/nclex_q.php?qn_id=543284)

---

More free questions: [기출문제](https://mymerci.kr/)

_학습 참고용입니다. 실제 임상은 최신 지침과 소속 기관 프로토콜을 따르세요._