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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Free Nursing Study Resources

Correct Answer is D

Explanation

A. "Hair growth in the pubic area begins before breast development.": In females, breast development (thelarche) typically precedes pubic hair growth (pubarche). This statement is inaccurate and does not reflect the normal sequence of pubertal changes.

B. "Puberty begins with a female's first menstrual cycle.": Menarche occurs later in puberty, usually around Tanner stage 3–4, and is not the initial sign of pubertal development. Puberty begins with the onset of breast development and other secondary sexual characteristics.

C. "Females will stop growing by the age of 14.": Growth in females continues for several years after the onset of puberty, often until 16–18 years of age, depending on the timing of menarche and individual growth patterns. Stating age 14 is inaccurate.

D. "Females begin puberty about 2 years earlier than males.": This statement is accurate. On average, females begin puberty between ages 8–13, while males typically start between ages 10–15, reflecting the earlier onset of secondary sexual characteristics in females.

A. Denial B. Reorganization C. Numbing D. Reinvesting

Correct Answer is A

Explanation

A. Denial: Denial is an expected initial stage of grief in response to terminal illness. Clients may have difficulty accepting the diagnosis and may refuse to believe the reality of their condition as a coping mechanism.

B. Reorganization: Reorganization is a later stage of grief associated with adapting to loss after bereavement. It is not typically part of the immediate response to a terminal diagnosis in the dying process.

C. Numbing: Numbing is more commonly associated with acute grief reactions following sudden loss, rather than the anticipatory grief experienced after a terminal diagnosis.

D. Reinvesting: Reinvesting refers to redirecting emotional energy into new relationships or activities after loss. This stage occurs after bereavement and is not part of the expected stages of grief during the dying process.

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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 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.