A nurse is caring for a 2-day-old newborn who is undergoing phototherapy for treatment of hyperbilirubinemia.
Which of the following actions should the nurse take?
Provide additional hydration by offering glucose water.
Monitor the newborn’s heart rate every 2 hours.
Apply a water-based lotion to the newborn’s skin every 4 hours.
Remove the newborn from phototherapy every 2 hours for breastfeeding.
The Correct Answer is D
Choice A rationale
Providing additional hydration by offering glucose water is not recommended. Breast milk or formula should be the primary source of hydration for newborns.
Choice B rationale
Monitoring the newborn’s heart rate every 2 hours is not necessary for phototherapy. The focus should be on monitoring bilirubin levels, hydration status, and ensuring the newborn’s eyes are protected.
Choice C rationale
Applying a water-based lotion to the newborn’s skin every 4 hours is not recommended. Lotions can interfere with the effectiveness of phototherapy and may cause skin irritation.
Choice D rationale
Removing the newborn from phototherapy every 2 hours for breastfeeding is recommended. Frequent breastfeeding helps to promote bilirubin excretion and maintain hydration.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["4"]
Explanation
Step 1 is to determine the total dosage required: 2 g = 2000 mg.
Step 2 is to calculate the number of tablets needed: 2000 mg ÷ 500 mg/tablet = 4 tablets. The nurse should administer 4 tablets.
Correct Answer is A
Explanation
Choice A rationale
Retained placental fragments are a significant risk factor for postpartum hemorrhage. If parts of the placenta remain attached to the uterine wall, it can prevent the uterus from contracting properly, leading to excessive bleeding.
Choice B rationale
Breech presentation is not a direct risk factor for postpartum hemorrhage. While it can complicate delivery, it does not directly cause hemorrhage.
Choice C rationale
Urinary tract infection is not a risk factor for postpartum hemorrhage. It can cause other complications but does not directly lead to hemorrhage.
Choice D rationale
Oligohydramnios, or low amniotic fluid, is not a risk factor for postpartum hemorrhage. It can cause complications during pregnancy but does not directly lead to hemorrhage.
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