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.

Answer and Explanation

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.

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Correct Answer is B

Explanation

A. Skin integrity should be assessed more frequently, generally every 2 hours.

B. Continuous visual monitoring is required to ensure the safety and well-being of a client who is in mechanical restraints, to respond promptly to any distress or complications.
C. Restraints should be a last resort and not prescribed as needed.

D. The provider should evaluate the client sooner, typically within 1 hour of applying restraints.

A. Chorioamnionitis B. Fetal anemia C. Maternal hypoglycemia D. Maternal fever

Correct Answer is C

Explanation

A. Chorioamnionitis, an infection of the fetal membranes, can lead to fetal tachycardia and no bradycardia
B. Fetal anemia might present with tachycardia rather than bradycardia.

C. Maternal hypoglycemia can cause fetal bradycardia since when a mother experiences hypoglycemia, it can result in inadequate blood glucose levels that are crucial for both her and the fetus. This condition can impair the oxygen and nutrient delivery to the fetus, as the mother's body prioritizes her own metabolic needs. Consequently, the fetal heart rate may slow down as a response to the stress of reduced energy supply.
D. Maternal fever is associated with fetal tachycardia rather than bradycardia.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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