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.

Supplement feeding with sterile water.

Dress in only a diaper.

Cover newborn's eyes with a shield.

Breastfeed every 2 to 3 hr.

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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Correct Answer is C

Explanation

A. The infant is swaddled but there is a blanket and a stuffed toy in the crib. Loose items increase the risk of suffocation and SUID, so this does not demonstrate safe sleep practices.

B. The infant is placed on their back, but there is a blanket and a stuffed toy in the crib. These items pose a suffocation risk and do not follow safe sleep guidelines.

C. The infant is placed on their back in a swaddle with no loose blankets or toys in the crib. This position aligns with American Academy of Pediatrics (AAP) recommendations for safe sleep to reduce the risk of SUID, demonstrating proper understanding of safe sleep practices.

A. Delegate scheduled checks to assistive personnel. B. Ensure all the side rails are up when the client is in bed. C. Collaborate with a provider to request PRN standard prescriptions for sedatives. D. Keep televisions on around the unit for distraction.

Correct Answer is A

Explanation

A. Delegate scheduled checks to assistive personnel: Regular, scheduled checks help monitor clients with moderate dementia for signs of restlessness, wandering, or unsafe behaviors that could lead to falls. Delegating this task ensures consistent supervision and enhances safety.

B. Ensure all the side rails are up when the client is in bed: Raising all side rails can actually increase the risk of injury, as clients with dementia may attempt to climb over them, leading to falls or entrapment. Side rails should be used judiciously and according to safety guidelines.

C. Collaborate with a provider to request PRN standard prescriptions for sedatives: Routine use of sedatives can increase confusion, dizziness, and fall risk in clients with dementia. Nonpharmacologic fall prevention strategies are preferred whenever possible.

D. Keep televisions on around the unit for distraction: Continuous background noise or television can be overstimulating and may increase agitation in clients with dementia, potentially increasing the risk of falls rather than preventing them.

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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.

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A nurse is teaching about preventing sudden unexpected infant death (SUID) to a parent of a 1-month-old infant. Which of the following ling indicates that the parent understands how to place the infant in the crib at bedtime?

Correct Answer is C

Explanation

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Correct Answer is A

Explanation

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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.