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
The correct answer is choice c. Verbalizing the importance of monitoring for medication side effects.
Choice A rationale:
Relieving constipation is not typically a priority for patients with Graves’ disease, as constipation is not a common symptom of this condition.
Choice B rationale:
While involving adolescents in their care decisions is important, allowing them to decide whether or not to take medication is not appropriate. Adherence to medication is crucial for managing Graves’ disease.
Choice C rationale:
Verbalizing the importance of monitoring for medication side effects is essential. Graves’ disease treatment often involves medications that can have significant side effects, and monitoring these is critical for effective management and patient safety.
Choice D rationale:
Developing alternative educational goals is not directly related to the immediate management of Graves’ disease. While educational support is important, it is not the primary nursing goal in this context.
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.
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