A nurse is caring for a 1-day-old newborn who has jaundice and is receiving phototherapy. Which of the following actions should the nurse take?
Keep the infant's head covered with a cap.
Apply lotion to the newborn every 4 hr.
Give the infant 30 mL (1 oz) of glucose water every 2 hr.
Ensure that the newborn wears a diaper.
The Correct Answer is D
A. The infants’s head should not be covered while receiving phototherapy, as the skin needs to be exposed to the therapy. However, it is essential to ensure that the infant's eyes are protected from the light.
B. Applying lotion may interfere with the effectiveness of phototherapy by blocking the light’s effects and is unnecessary for managing jaundice in newborns.
C. Giving glucose water is unnecessary and may interfere with the infant's hydration and nutritional needs during phototherapy.
D. Ensuring that the newborn wears a diaper to prevent soiling of the phototherapy equipment and to allow for the monitoring of urinary output, which is an important indicator of the newborn's health during treatment.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","D","E","G"]
Explanation
A. The client's nightmares could be indicative of post-traumatic stress disorder (PTSD), especially after the client’s parents and a sibling passed away from injuries sustained when a tornado moved through their town 1 month ago.
B. A heart rate of 99/min is within the normal range for the client’s age and requires no need for follow-up.
C. While regular attendance at school is generally considered a positive behavior, it does not directly indicate a need for immediate follow-up. However, it is relevant information for assessing the client's overall functioning and resilience in the context of their recent traumatic experience.
D. The client's use of marijuana as a coping mechanism raises concerns about their mental health and potential substance abuse. Immediate follow-up is needed to address this issue and provide appropriate support and intervention.
E. Startles easily during thunderstorms and witnessing their family's death are findings that indicate symptoms of post-traumatic stress disorder (PTSD) or acute stress reaction following the traumatic event of witnessing their family's death. Immediate follow-up is
necessary to assess the client's mental health status and provide appropriate support and counseling.
F. A blood pressure of 122/80 mm Hg falls within the normal range for adolescents and does not indicate an immediate medical concern. While blood pressure monitoring is important for overall health assessment, this finding alone does not warrant immediate follow-up in the context of the client's presenting issues.
G. The caregiver's observation that the client is acting differently than usual suggests a change in behavior or mental health status that requires further assessment and intervention. Immediate follow-up is needed to explore the caregiver's concerns and address any underlying issues affecting the client's well-being
Correct Answer is C
Explanation
A. Absence seizures typically last only a few seconds, not as long as 30 to 60 seconds, so this statement is incorrect.
B. Absence seizures typically occur without warning or aura, so this statement is incorrect.
C. Absence seizures often manifest as brief episodes of staring or blank expression, which can be mistaken for daydreaming or inattention. Educating parents about this characteristic helps them recognize and appropriately respond to absence seizures in their child.
D. Absence seizures have a sudden onset and offset without warning, so this statement is incorrect.
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