A nurse is assessing a newborn who is receiving dual phototherapy via overhead lights and a fiberoptic pad for the treatment of hyperbilirubinemia. Which of the following actions should the nurse take?
Maintain therapy with the fiber optic pad while having the parent hold the newborn during feedings.
Discontinue the overhead lights when the newborn has three seedy stools within 2 hr.
Swaddle the newborn in a light blanket before placing them on the fiber optic pad.
Determine the positioning of overhead lights by assessing the newborn's axillary temperature.
The Correct Answer is A
Choice A reason: Maintaining therapy with the fiber optic pad while allowing parental holding during feedings is correct because it ensures continuous treatment while promoting bonding and feeding. Fiberoptic phototherapy pads are safe to use during holding, and they do not interfere with feeding. This approach balances effective bilirubin reduction with essential parent-infant interaction, which supports emotional well-being and breastfeeding success.
Choice B reason: Discontinuing overhead lights based on stool frequency is incorrect. Increased stooling is a common effect of phototherapy due to bilirubin excretion, but it is not a criterion for discontinuation. Therapy is guided by bilirubin levels and clinical assessment, not stool count. Stopping therapy prematurely could result in rebound hyperbilirubinemia.
Choice C reason: Swaddling the newborn before placing them on the fiber optic pad is inappropriate because swaddling blocks light exposure to the skin, reducing the effectiveness of phototherapy. Direct skin exposure is necessary for maximum bilirubin breakdown.
Choice D reason: Determining the positioning of overhead lights by assessing axillary temperature is incorrect. Temperature monitoring is important to prevent overheating, but light positioning is determined by distance and angle to maximize skin exposure, not by temperature readings.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A reason: An oral temperature of 35.4° C (95.7° F) indicates hypothermia, which is a serious complication of eating disorders such as anorexia nervosa. Hypothermia suggests severe malnutrition and impaired thermoregulation, requiring immediate medical evaluation. This makes option A the correct answer.
Choice B reason: A resting heart rate of 60/min is within the normal range for adults. While bradycardia can occur in clients with eating disorders, a rate of 60/min is not alarming and does not require urgent referral. This option is incorrect.
Choice C reason: A urine output of 320 mL in 8 hours is slightly below the expected minimum of 30 mL per hour (240 mL in 8 hours). While this is reduced, it is not critically low and does not immediately necessitate referral unless it persists or worsens. This option is incorrect.
Choice D reason: A blood pressure of 100/68 mm Hg is within the normal range and does not indicate an acute complication. This option is incorrect because it does not represent a dangerous finding.
Correct Answer is D
Explanation
Choice A reason: Serous drainage at the insertion site may indicate mild irritation but does not require discontinuation unless accompanied by signs of infection or infiltration.
Choice B reason: A small air bubble in the tubing is generally harmless and does not require discontinuation. Large air bubbles pose a risk of air embolism, but small ones are typically absorbed without issue.
Choice C reason: Blood return in the tubing indicates that the IV catheter is correctly placed in the vein. This is a normal finding and does not require discontinuation.
Choice D reason: Blanched skin at the insertion site indicates infiltration, meaning IV fluid is leaking into surrounding tissue rather than the vein. This can cause tissue damage and requires immediate discontinuation of the IV to prevent complications.
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