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
Explanation
A. Phenytoin should be taken with food to minimize gastrointestinal side effects and enhance absorption.
B. There is no specific requirement to limit foods containing vitamin D while taking phenytoin.
C. Phenytoin does not typically interfere with folic acid metabolism, so there is no need to limit foods containing folic acid.
D. Phenytoin should not be taken with antacids, as they can decrease its absorption.
Correct Answer is ["B","E","G","F","H"]
Explanation
A. While monitoring blood pressure is essential in the overall assessment of a patient, the given blood pressure readings (112/88 mm Hg) are within the normal range. Hence, further evaluation of blood pressure may not be immediately necessary based on the provided information.
B. A temperature of 38.1°C (100.5°F) indicates fever, which can be a sign of infection or inflammatory process. Further evaluation is warranted to determine the cause of the fever and initiate appropriate treatment.
C. The heart rate of 98/min falls within the normal range for adults (60-100 beats per minute). Although heart rate abnormalities can indicate various conditions, the given heart rate alone may not warrant immediate further evaluation without additional concerning symptoms or clinical context.
D. The oxygen saturation of 98% on room air is within the normal range (>95%).
While assessing oxygen saturation is crucial, the provided value does not indicate immediate concern. Further evaluation may be needed if the patient shows signs of respiratory distress or if there is clinical suspicion of hypoxemia.
E. Recent travel to South Africa raises concerns about potential exposure to infectious diseases endemic to that region. Further evaluation is necessary to assess for travel- related illnesses or infections, such as tuberculosis or other tropical diseases.
F. A significant weight loss of 2.26 kg (5 lb) over the last week is concerning and requires further investigation. Unintentional weight loss can be indicative of various underlying medical conditions, including infections, malignancies, or metabolic disorders.
G. The report of "blood-tinged sputum" suggests hemoptysis, which can be a sign of serious underlying conditions such as pulmonary infections, pulmonary embolism, or malignancy. Further evaluation is necessary to determine the cause and initiate appropriate management.
H. The presence of a persistent cough, especially when associated with other symptoms like fatigue, night sweats, and weight loss, raises concerns for underlying respiratory or systemic conditions. Further assessment is needed to identify the cause of the cough and provide appropriate treatment.
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