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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. Position the newborn on their abdomen after feeding: Placing a newborn on their abdomen after feeding increases the risk of aspiration and sudden infant death syndrome (SIDS). The recommended position after feeding is upright or on their back when sleeping.
B. Place the newborn on a rigid feeding schedule: Strict feeding schedules can lead to overfeeding or underfeeding, both of which can increase spit-up. Feeding on demand or according to the newborn’s hunger cues is safer and helps minimize gastrointestinal discomfort.
C. Offer the newborn a pacifier after feedings: Using a pacifier may soothe the newborn but does not reduce the incidence of spit-up. It is unrelated to gastric emptying or swallowing air during feeding.
D. Burp the newborn several times during the feeding: Frequent burping helps release swallowed air, which can decrease gastric distention and reduce spit-up. This technique is an effective intervention to minimize discomfort and regurgitation in formula-fed newborns.
Correct Answer is ["A","B","E","G"]
Explanation
A. Obtain a brain natriuretic peptide (BNP) test: BNP is a marker of heart failure and is indicated given the client’s new-onset dyspnea, crackles, and S3/S4 heart sounds. Measuring BNP helps assess for possible acute decompensated heart failure following surgery.
B. Obtain a complete blood count: A CBC helps identify infection, anemia, or other hematologic changes that could contribute to dyspnea, tachypnea, or hypoxia in the postoperative client. The client’s fever and tachycardia warrant this assessment.
C. Request respiratory therapy for intubation: Intubation is not immediately indicated as the client is still alert, maintaining oxygen saturation of 92% on supplemental oxygen. Less invasive diagnostics and interventions are prioritized first.
D. Obtain a STAT MRI: MRI is not the first-line diagnostic tool for acute dyspnea and postoperative cardiopulmonary assessment. It is not indicated in emergent evaluation of pulmonary or cardiac complications.
E. Obtain ABGs: Arterial blood gases are important to assess oxygenation, ventilation, and acid-base status given the client’s tachypnea, hypoxemia, and sudden respiratory distress.
F. Prepare the client for cardiac catheterization: Cardiac catheterization is invasive and not the immediate priority. Initial noninvasive assessment should guide the need for further intervention.
G. Obtain a chest x-ray: A chest x-ray is indicated to assess for pulmonary edema, pleural effusion, or other cardiopulmonary complications in a postoperative client presenting with dyspnea, crackles, and hypoxia.
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