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 B
Explanation
A. This advice may lead to inadequate emptying of the breasts and imbalance in milk production, potentially affecting milk supply and infant feeding.
B. Encouraging feeding on demand promotes effective breastfeeding by allowing the infant to feed when hungry, which helps establish and maintain milk supply. This approach supports infant cues and promotes successful breastfeeding.
C. Strict time limits on feeding can interfere with effective breastfeeding and hinder milk transfer, potentially leading to inadequate nutrition for the infant.
D. Water supplementation is unnecessary for breastfed infants and can interfere with breastfeeding by reducing infant appetite for breast milk.
Correct Answer is B
Explanation
A. Flattening of the artificial airway cuff. This would indicate a problem, such as a leak, not a successful outcome of suctioning.
B. This indicates that the airway resistance has been reduced following suctioning, which suggests that the suctioning was effective in clearing the airway obstruction caused by secretions.
C. Thinning of mucous secretions is not a direct indication of effective suctioning; while thinner secretions may be easier to remove, the goal of suctioning is to clear the airways rather than alter the consistency of the secretions.
D. The presence of a productive cough is not relevant in the context of a patient who is intubated and mechanically ventilated, as they would be unable to cough effectively due to the endotracheal tube.
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