A newborn is jaundiced and receiving phototherapy 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
Choice A rationale:
Applying oil-based lotion is not recommended during phototherapy as it can block the pores and reduce the effectiveness of the therapy. The baby's skin should be exposed to the light as much as possible to treat hyperbilirubinemia effectively.
Choice B rationale:
Limiting the newborn's intake of milk is not appropriate. Adequate hydration and nutrition are essential for infants, especially those undergoing phototherapy. Dehydration can worsen jaundice, so the baby should be encouraged to feed frequently.
Choice C rationale:
Placing eye shields over the newborn's closed eyes is essential during phototherapy. Exposure to high-intensity light can damage the baby's eyes, so protecting the eyes with shields is necessary.
Choice D rationale:
Changing the newborn's position every 2-3 hours is recommended during phototherapy. This helps ensure that all parts of the baby's skin receive equal exposure to the light, maximizing the effectiveness of the treatment.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A rationale:
Most mothers do not have a diet deficient in vitamin K that would result in the infant being deficient. Vitamin K is essential for blood clotting, and it is generally present in adequate amounts in a well-balanced diet.
Choice B rationale:
Vitamin K does play a role in the synthesis of prothrombin, a clotting factor in the liver, but it is not the primary reason for administering vitamin K to newborns. The main reason is the absence of vitamin K-synthesizing bacteria in the newborn's intestinal tract.
Choice C rationale:
The correct answer. Newborns do not have the bacteria in their intestines necessary to produce vitamin K, which is crucial for blood clotting. Without sufficient vitamin K, newborns are at risk of bleeding disorders, including a potentially fatal condition called vitamin K deficiency bleeding (VKDB).
Choice D rationale:
While it's true that the supply of vitamin K from the mother to the baby is limited during pregnancy and breastfeeding, the main reason for administering vitamin K to newborns is the absence of bacteria that can synthesize vitamin K in the infant's intestinal tract.
Correct Answer is A
Explanation
Choice A rationale:
Afterbirth hemorrhage, or postpartum hemorrhage (PPH), is a significant concern after childbirth. One of the common causes is retained placental fragments. When placental tissue is not completely expelled after delivery, it can lead to continuous bleeding. This condition requires prompt medical intervention, often through uterine exploration and removal of the retained tissue.
Choice B rationale:
Unrepaired vaginal lacerations can cause bleeding, but they are usually identified and repaired immediately after delivery. In this case, the woman gave birth 4 hours ago, so unrepaired lacerations would have been addressed during the delivery process.
Choice C rationale:
Uterine atony, which is the lack of normal uterine muscle tone, can cause postpartum hemorrhage. However, in this scenario, the woman was given Pitocin, which is an oxytocic medication used to prevent or treat uterine atony by inducing uterine contractions. Therefore, uterine atony is less likely to be the cause in this case.
Choice D rationale:
Puerperal infection, also known as postpartum infection, can cause fever, uterine tenderness, and foul-smelling discharge. While it can lead to complications, it is not the most likely cause of significant bleeding in this situation.
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