A nurse is caring for a 2-day-old newborn who has a bilirubin level of 14 mg/dL (1 to 12 mg/dL) and is to begin phototherapy.
Which of the following actions should the nurse take?

Give glucose water after feedings.

Instruct the client to avoid breastfeeding during treatment.

Monitor intake and output.

Apply lotions and ointments throughout the treatment.

Answer and Explanation

The Correct Answer is C

Choice A rationale

Giving glucose water after feedings is not recommended for newborns undergoing phototherapy. Breastfeeding or formula feeding should be continued to provide adequate nutrition and hydration.

Choice B rationale

Instructing the client to avoid breastfeeding during treatment is not necessary. Breastfeeding should continue to promote bonding, provide nutrition, and help with the infant's hydration and bilirubin excretion.

Choice C rationale

Monitoring intake and output is crucial for a newborn receiving phototherapy to ensure proper hydration and assess the effectiveness of the treatment in lowering bilirubin levels.

Choice D rationale

Applying lotions and ointments throughout the treatment is not recommended, as they can interfere with the effectiveness of phototherapy. The skin should be clean and dry to maximize exposure to the phototherapy light.

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Correct Answer is A

Explanation

Choice A rationale

Checking fetal heart tones is the priority to assess the well-being of the fetus, especially in breech presentation and after the membranes have ruptured.

Choice B rationale

Preparing for a cesarean birth is important but follows the assessment of fetal heart tones and other immediate measures.

Choice C rationale

Checking the color, amount, and odor of the fluid is important, but ensuring fetal heart tones comes first to monitor any distress.

Choice D rationale

Performing a Nitrazine test to assess for rupture of membranes is redundant once the client reports her water has broken.

A. Begin each feeding with the breast that is most sore, so the newborn spends less time on it. B. Use breast pads with a moisture-proof lining to keep the nipples moist. C. Breastfeed the baby less frequently to give the nipples time to heal. D. Apply colostrum to the nipples after feeding to help them heal.

Correct Answer is D

Explanation

Choice A rationale

Starting each feeding with the most sore breast can worsen the condition, as the infant initially sucks more vigorously at the beginning of a feeding. This might increase the pain and damage to the already sore breast.

Choice B rationale

Moisture-proof lining in breast pads can cause an accumulation of moisture, creating a breeding ground for bacteria. This can exacerbate soreness and lead to infections such as mastitis.

Choice C rationale

Breastfeeding less frequently can lead to engorgement and plugged ducts, which can further complicate breast soreness and potentially decrease milk supply. Regular feeding helps in maintaining milk flow and production.

Choice D rationale

Colostrum has natural healing properties, including immunoglobulins and growth factors, that can help heal sore and cracked nipples. Applying colostrum can promote faster recovery and reduce discomfort.

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A nurse is caring for a 2-day-old newborn who has a bilirubin level of 14 mg/dL (1 to 12 mg/dL) and is to begin phototherapy.Which of the following actions should the nurse take?

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A nurse is caring for a 2-day-old newborn who has a bilirubin level of 14 mg/dL (1 to 12 mg/dL) and is to begin phototherapy.
Which of the following actions should the nurse take?