A nurse is assessing a client who has pericarditis. Which of the following findings is the priority?

 

- A. Clothing the newborn in light cotton is not recommended because it can block the light from reaching the skin, which is necessary for the treatment of hyperbilirubinemia through phototherapy.
- B. Checking the newborn's temperature every 8 hours is not frequent enough; during phototherapy, it is important to monitor the newborn's temperature more frequently to ensure they do not become too cold or too warm as a result of the therapy.
- C. Administering water between feedings is not recommended as it can interfere with the newborn's feeding schedule and nutrition; breast milk or formula provides adequate hydration unless otherwise indicated by a healthcare provider.
- D. Placing the newborn 45 cm (18 in) from the light source is the correct intervention. This distance allows for optimal exposure to the light while ensuring the safety and comfort of the newborn, as recommended in clinical guidelines for effective phototherapy.

A. Speaking directly into one of the client's ears may be ineffective if the client has bilateral hearing impairment or if the hearing impairment is not related to the ear anatomy.

B. Rephrasing sentences the client does not understand can help clarify communication and ensure the client receives necessary information.

C. Dropping voice volume at the end of sentences can make it difficult for the client to hear the entire message, especially if the client relies on lip-reading or amplification devices.

D. Exaggerating lip movements may not be helpful for all clients with hearing impairment and may not accurately convey the intended message. Instead, clear and natural lip movements should be used along with other communication strategies such as rephrasing sentences and facing the client directly.