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A nurse is caring for a 36-hr old infant.

The nurse is preparing the infant for phototherapy.

For each nursing action, click to specify if the action is indicated or contraindicated for the newborn.

A.

Supplement feeding with sterile water.

B.

Dress in only a diaper.

C.

Cover newborn's eyes with a shield.

D.

Breastfeed every 2 to 3 hr.

E.

Apply lotion to skin every 4 hr.

Answer and Explanation

The Correct Answer is {"A":{"answers":"B"},"B":{"answers":"A"},"C":{"answers":"A"},"D":{"answers":"A"},"E":{"answers":"B"}}

Rationale

• Supplement feeding with sterile water: Sterile water provides no nutritional value and dilutes electrolyte balance, increasing health risks without reducing bilirubin. It can interfere with adequate breast milk intake, which is essential for promoting bilirubin excretion. Hydration for jaundiced infants must come from breast milk or formula, not water.

• Dress in only a diaper: Phototherapy requires maximum skin exposure so bilirubin can be broken down effectively through light absorption. Limiting clothing allows more surface area to receive therapeutic light. Keeping only a diaper on also prevents overheating or obstruction from unnecessary garments. This setup ensures optimal treatment efficiency.

• Cover newborn’s eyes with a shield: The bright phototherapy lights can damage the newborn’s developing retina, so eye protection is essential. Soft shields prevent retinal injury while still allowing the infant to move comfortably. The shields are removed only during feeding or parent interaction to allow bonding. Consistent use is a critical safety component of phototherapy.

• Breastfeed every 2 to 3 hr: Frequent breastfeeding promotes bilirubin excretion through stooling and hydration, supporting the infant’s ability to lower bilirubin naturally. More frequent feeds also prevent lethargy from worsening and help maintain stable glucose levels. Breast milk intake is a key measure for preventing severe hyperbilirubinemia progression during phototherapy.

• Apply lotion to skin every 4 hr: Lotions can absorb heat and increase skin irritation under phototherapy lights. Some topical products may also intensify light absorption, raising the risk of burns. The newborn’s skin must remain clean and dry to prevent adverse reactions. Avoiding lotions keeps the skin safe during therapy.


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Related Questions

Correct Answer is D

Explanation

A. A 32-year-old client who has chlamydia: Chlamydia is a sexually transmitted infection that is not transmitted via airborne or droplet routes. Standard precautions are sufficient, and a private room is not required.

B. A 50-year-old client who has Candida albicans: Candida infections are generally superficial and not highly contagious. Standard precautions are adequate, so a private room is not necessary.

C. A 25-year-old client who has vaginal trichomonas: Trichomoniasis is a sexually transmitted infection and does not require isolation. Standard precautions are appropriate for this client.

D. A 40-year-old client who has streptococcal pharyngitis: Streptococcal pharyngitis is transmitted via respiratory droplets. Placing the client in a private room or with another client who has the same infection helps prevent transmission, making a private room the most appropriate assignment.

Correct Answer is A

Explanation

A. Health department data and statistics reports: Local or state health departments routinely collect and publish epidemiological data, including incidence and prevalence rates of communicable diseases like tuberculosis. These reports provide reliable, up-to-date statistics that are essential for planning and evaluating public health programs.

B. Expert opinion from local health care providers: Expert opinion can provide insights into trends or clinical observations, but it is anecdotal and not sufficient for calculating incidence rates. Public health planning requires data that is systematically collected and analyzed.

C. Browsing an internet search engine: While internet searches may yield general information, the results may not be accurate, up-to-date, or specific to the local population. Official health department sources are more reliable for incidence data.

D. Clinical guidelines from a professional organization: Clinical guidelines provide recommendations for diagnosis, treatment, and management, but they do not usually include local incidence statistics. They are not a primary source for epidemiological data.

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