A newborn is jaundiced and receivesphototherapy via ultraviolet bank lights.
An appropriate nursing intervention when caring for an infant with hyperbilirubinemia and receiving phototherapy by this method would be to:
Apply an oil-based lotion to the newborn’s skin to prevent drying and cracking.
Limit the newborn’s intake of milk to prevent nausea, vomiting, and diarrhea.
Place eye shields over the newborn’s closed eyes.
Change the newborn’s position every 4 hours.
The Correct Answer is C
Placing eye shields over the newborn’s closed eyes. This is because phototherapy can cause eye damage and irritation to the newborn, so eye protection is essential.
Choice A is wrong because oil-based lotion can increase the absorption of heat and cause burns to the newborn’s skin.
Choice B is wrong because limiting the newborn’s intake of milk can cause dehydration and increase the risk of hyperbilirubinemia.
Choice D is wrong because changing the newborn’s position every 4 hours is not frequent enough to prevent pressure ulcers and ensure even exposure to the light.
Normal ranges for bilirubin levels in newborns are 1 to 12 mg/dL for term infants and 3 to 14 mg/dL for preterm infants. Phototherapy is usually indicated when the bilirubin level exceeds 15 mg/dL for term infants and 10 mg/dL for preterm infants.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Children with asthma who are taking long-term inhaled steroids should be assessed frequently to monitor for this increased risk because some studies have shown a growth delay in children treated with moderate to high doses of inhaled steroids. This appears to occur only during the first year of treatment and may be reversible.
Choice A is wrong because cough is not a side effect of inhaled steroids, but a symptom of asthma itself.
Choice B is wrong because osteoporosis is not a common side effect of inhaled steroids in children, but a possible risk for adults who use high doses of inhaled steroids or oral steroids.
Choice D is wrong because Cushing’s syndrome is not a side effect of inhaled steroids, but a rare complication of oral steroids.
Correct Answer is D
Explanation
Digoxin is a medication that helps improve the pumping function of the heart and reduces fluid retention in the lungs and other tissues. It is commonly used to treat congestive heart failure in infants.
Choice A is wrong because weighing the infant every day on the same scale at the same time is a way to monitor fluid balance, not an intervention to treat excess fluid volume.
Choice B is wrong because notifying the physician when weight gain exceeds more than 20 g/day is also a monitoring measure, not an intervention. Moreover, weight gain may not accurately reflect fluid volume status in some patients with heart failure due to poor nutrition and decreased appetite.
Choice C is wrong because putting the infant in a car seat to minimize movement may worsen the respiratory distress and increase the workload of the heart. The infant should be positioned in a semi-Fowler’s or Fowler’s position to facilitate breathing and reduce venous return.
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