A nurse is assisting in the care of a newborn who is scheduled for a heel stick for genetic screening.
Which of the following actions by the nurse demonstrates correct pain relief techniques for newborns?
Feed the newborn water during the procedure.
Place the newborn's arms and legs in flexion and close to the midline of the torso.
Place the newborn supine during the procedure.
Elevate the newborn's head during the procedure.
The Correct Answer is B
Choice A rationale
Feeding the newborn water during the procedure is incorrect because water does not provide effective pain relief during procedures.
Choice B rationale
Placing the newborn's arms and legs in flexion and close to the midline of the torso is correct as this position, known as facilitated tucking, provides comfort and can help reduce pain.
Choice C rationale
Placing the newborn supine during the procedure is incorrect because it does not provide any specific pain relief benefits.
Choice D rationale
Elevating the newborn's head during the procedure is not specifically related to pain relief but is more about positioning for ease of access. .
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale
Checking the fetal heart rate pattern is the priority after an amniotomy. This procedure involves breaking the amniotic sac, which can lead to changes in the fetal heart rate. Immediate assessment ensures the fetus is not in distress.
Choice B rationale
Evaluating for signs of infection is essential post-procedure, but not the immediate priority. Infection signs develop over time, while fetal distress can occur immediately.
Choice C rationale
Observing the color and consistency of amniotic fluid is important for identifying meconium-stained fluid, but it is not as immediately crucial as ensuring fetal well-being.
Choice D rationale
Taking the client's temperature can help monitor for infection later, but it is not the immediate concern following amniotomy. The primary concern is the fetal response.
Correct Answer is C
Explanation
Choice A rationale
An increase in serum bilirubin levels indicates worsening hyperbilirubinemia rather than improvement. Effective phototherapy should result in a decrease in bilirubin levels as it helps break down bilirubin into a form that can be excreted.
Choice B rationale
Hemoglobin and hematocrit levels are not directly affected by phototherapy. These values are more related to red blood cell count and do not indicate the effectiveness of phototherapy for treating hyperbilirubinemia.
Choice C rationale
A decrease in transcutaneous bilirubin (TcB) levels from 6 hours ago indicates effective phototherapy. Phototherapy reduces bilirubin levels in the blood by converting it to a water-soluble form that can be eliminated from the body.
Choice D rationale
Jaundice typically moves from the head to the lower body as bilirubin levels decrease. Movement from chest to groin level without a corresponding decrease in bilirubin levels does not necessarily indicate effective phototherapy. .
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