A telephone triage nurse gets a call from a postpartum patient who is concerned about jaundice. The patient's newborn is 37 hours old. What data point should the nurse gather first?

Question

Quizplus · Accepted Answer

The first data point the nurse should gather is the infant's skin color as jaundice is characterized by yellowing of the skin and sclera. This will give the nurse an initial indication of the severity of the jaundice and the need for further assessment or intervention. Stool characteristics and fluid intake may also be important to gather in assessing the infant's overall health, but these are not as directly relevant to the concern of jaundice. Bilirubin level would require further testing and cannot be assessed through a telephone call.

A Telephone Triage Nurse Gets a Call from a Postpartum