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
Bacteria that synthesize vitamin K is not present in the newborn’s intestinal tract. Vitamin K is essential for blood clotting, and newborns are at risk of bleeding problems due to their lack of vitamin K. Therefore, vitamin K is given by injection to prevent hemorrhagic disease in the newborn.
Choice A is wrong because most mothers do not have a diet deficient in vitamin K, and vitamin K deficiency in newborns is not related to the maternal diet.
Choice B is wrong because vitamin K does not prevent the synthesis of prothrombin in the liver, but rather enhances it. Prothrombin is a clotting factor that requires vitamin K for its production.
Choice D is wrong because the supply of vitamin K is not inadequate for at least 3 to 4 months, but rather for a few days until the newborn’s intestinal bacteria start producing it.
Correct Answer is A
Explanation
Vernix caseosa is a cheese-like, whitish substance that fuses with the epidermis and serves as a protective coating for the newborn.
Some possible explanations for the other choices are:
- Choice B. Surfactant is a protein that lines the alveoli of the infant’s lungs and helps prevent them from collapsing.
- Choice C. Caput succedaneum is a swelling of the tissue over the presenting part of the fetal head caused by pressure during delivery.
- Choice D. Acrocyanosis is a bluish discoloration of the hands and feet due to reduced peripheral circulation.
Normal ranges for vernix caseosa are not applicable as it varies depending on the gestational age and skin maturity of the newborn. However, it is usually more abundant in preterm infants than in term or post-term infants.
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