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.

Answer and Explanation

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.

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Free Nursing Study Resources

Correct Answer is ["A","B","D"]

Explanation

Rationale:

• "Use sunglasses if your eyes are sensitive to light." Exophthalmos from Graves' disease can persist even after thyroidectomy. Sunglasses help reduce photophobia and protect protruding eyes from dryness and injury.

• "Continue eating foods with protein." Protein is essential for wound healing and energy. Postoperative hypermetabolic states can also increase protein needs, so adequate intake supports recovery.

• "You need to support your neck when coughing or moving." Neck support prevents strain on the surgical site and reduces the risk of wound dehiscence or hematoma formation during activities that increase intrathoracic pressure.

• "Remain on bedrest for 3 to 5 days following discharge." Prolonged bedrest is not recommended post-thyroidectomy. Early ambulation reduces risk of complications such as pneumonia and deep vein thrombosis and supports normal recovery.

• "You will no longer need to take any medications for your thyroid now that you have had surgery." Total or subtotal thyroidectomy often results in hypothyroidism, requiring lifelong thyroid hormone replacement (e.g., levothyroxine). Medication needs depend on the amount of thyroid tissue removed.

A. Respiratory acidosis B. Hypertension C. Hypokalemia D. Hypermagnesemia

Correct Answer is C

Explanation

Rationale:

A. Respiratory acidosis: Chronic diarrhea typically causes metabolic acidosis due to loss of bicarbonate in the stool, not respiratory acidosis. Respiratory acidosis results from hypoventilation and CO₂ retention, unrelated to diarrhea.

B. Hypertension: Chronic diarrhea often leads to fluid and electrolyte imbalances causing hypotension or low blood pressure due to dehydration, rather than hypertension.

C. Hypokalemia: Diarrhea causes significant potassium loss through the gastrointestinal tract, leading to hypokalemia. Low potassium levels can result in muscle weakness, cramps, and cardiac arrhythmias.

D. Hypermagnesemia: Magnesium is usually lost during diarrhea, which more commonly leads to hypomagnesemia rather than elevated magnesium levels. Hypermagnesemia is rare unless there is excessive intake or renal failure.

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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?

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