新生兒哪項評估發現需要護理師進一步追蹤?
Which assessment finding in a newborn indicates a need for nursing follow-up?
- AHeart rate of 120 bpm心率为 120 bpm
- BRespiratory rate of 40 breaths per minute呼吸频率为每分钟 40 次
- CYellowish tint to the skin at 36 hours of life✓ 正解出生 36 小时后皮肤呈现黄染
- DPresence of a Moro reflex出现莫罗反射
新生兒黃疸(Jaundice)評估是臨床重點。一般而言,出生 24 小時內出現的黃疸被視為病理性(Pathological),需立即處理。本題中,新生兒在 36 小時出現黃疸,雖可能為生理性,但仍需與出生後的時間點、膽紅素數值及母嬰血型是否不合等因素綜合判斷。任何在出生後早期出現的黃疸,護理師都應警覺並進行追蹤(如測量經皮膽紅素指數),以防膽紅素腦病變(Kernicterus)。其他選項為新生兒常見的正常表現,不需過度擔憂。
Assessment of neonatal jaundice is a clinical priority. In general, jaundice appearing within the first 24 hours of life is considered pathological and requires immediate intervention. In this question, the neonate develops jaundice at 36 hours of age; although this may be physiological, it still requires comprehensive evaluation in light of the timing after birth, bilirubin level, and any maternal-infant blood group incompatibility. For any jaundice appearing early after birth, the nurse should be vigilant and conduct follow-up (such as measuring the transcutaneous bilirubin index) to prevent bilirubin encephalopathy (kernicterus). The other options describe common normal findings in the neonate and do not warrant excessive concern.