A nurse is caring for a newborn who has an order for phototherapy to treat hyperbilirubinemia. Which of the following actions should the nurse take?
Place eye covers on the newborn while under the lights.
Apply an emollient lotion to skin that is exposed to the lights.
Remove all blankets, clothing and diapers while the newborn is under lights
Keep the newborn as close to the light source as possible.
The Correct Answer is A
Rationale:
A. Place eye covers on the newborn while under the lights: Eye protection is essential during phototherapy to prevent retinal damage from the high-intensity blue light. The covers should be properly fitted and removed only during feedings or when the therapy is paused.
B. Apply an emollient lotion to skin that is exposed to the lights: Emollients are not recommended during phototherapy because they can increase the risk of burns or interfere with light penetration. The newborn’s skin should remain clean and dry to ensure safety and effective treatment.
C. Remove all blankets, clothing and diapers while the newborn is under lights: While minimal clothing is used to expose as much skin as possible, the diaper is typically kept in place to protect the genital area and reduce the risk of contamination. Full removal is not necessary or recommended.
D. Keep the newborn as close to the light source as possible: The distance between the newborn and the phototherapy light should be within manufacturer guidelines. Moving the newborn too close can increase the risk of overheating or skin damage, so positioning must follow safety standards.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Rationale:
A. Headaches with aura: Headaches accompanied by aura are a strong contraindication to oral contraceptive use due to the significantly increased risk of thromboembolic events, particularly ischemic stroke. Estrogen-containing contraceptives can further exacerbate this vascular risk, making alternative forms of birth control necessary.
B. Gastroesophageal reflux disease: GERD is a gastrointestinal condition that does not affect the safety or efficacy of oral contraceptives. Although hormonal fluctuations can sometimes influence gastric symptoms, GERD is not a contraindication to contraceptive use.
C. History of mononucleosis 1 year ago: A past infection with mononucleosis does not impact liver function long-term in most cases and does not interfere with hormonal contraceptive use. It does not pose any increased risk related to estrogen or progesterone components.
D. Irregular menstrual cycles: While irregular cycles are a common reason for initiating oral contraceptives, they are not a contraindication. In fact, hormonal contraceptives are often used therapeutically to regulate menstrual patterns and reduce cycle variability.
Correct Answer is C
Explanation
Rationale:
A. Oxytocin: Oxytocin is a uterotonic agent used to stimulate or augment labor, not to stop it. In the case of preterm labor at 36 weeks, administering oxytocin would worsen the situation by increasing uterine contractions and promoting delivery, which is not the intended goal.
B. Misoprostol: Misoprostol is typically used to induce labor by softening the cervix and stimulating contractions. It is contraindicated in clients experiencing preterm labor, as it would enhance uterine activity and could lead to premature delivery.
C. Magnesium sulfate: Magnesium sulfate is used in preterm labor to provide neuroprotection to the fetus and may also help reduce uterine contractions. It is especially indicated when labor is expected before 32–34 weeks but may still be prescribed at 36 weeks depending on clinical judgment.
D. Indomethacin: Indomethacin is a tocolytic agent used to suppress preterm labor contractions, but it is generally used before 32 weeks due to the risk of premature closure of the ductus arteriosus. At 36 weeks, the risks may outweigh the benefits, so it is not the first-line option at this gestational age.
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