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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Correct Answer is C

Explanation

Rationale:

A. Milk: Milk does not interfere with fecal occult blood testing and does not contain substances that cause false-positive results. It can be safely consumed prior to the test without affecting the accuracy of the results.

B. Whole wheat bread: Whole wheat bread is high in fiber, which is actually beneficial when preparing for a fecal occult blood test. It helps promote regular bowel movements but does not lead to false-positive results.

C. Red meat: Red meat contains heme, a form of animal blood, which can cause false-positive results on guaiac-based fecal occult blood tests. Avoiding red meat for at least 3 days prior to the test helps reduce the risk of inaccurate results.

D. Almonds: Almonds and other nuts do not contain components that interfere with fecal occult blood testing. They are not known to cause false-positive or false-negative results and are safe to consume before the test.

A. Ensure the transfusion tubing is flushed with dextrose 59% in water. B. Obtain a large-bore IV catheter. C. Witness the client signing a consent for transfusion. D. Ensure two nurses confirm the information on the blood label. E. Explain to the client that transfusion reactions are not serious.

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

Explanation

Rationale

• Ensure the transfusion tubing is flushed with dextrose 5% in water: Flushing with D5W can cause hemolysis due to the hypotonicity and sugar content, leading to clumping or damage to red blood cells. Normal saline is the only acceptable fluid for flushing or administering with blood products to maintain cell integrity and avoid adverse reactions.

• Obtain a large-bore IV catheter: A large-bore catheter, typically 18–20 gauge, is necessary to allow rapid infusion of blood and reduce the risk of hemolysis. It also minimizes resistance and facilitates effective delivery during emergencies like hypovolemic shock from GI bleeding.

• Witness the client signing a consent for transfusion: Informed consent is a legal and ethical requirement prior to initiating a transfusion. The nurse must ensure that the client understands the purpose, benefits, and risks of the procedure, and the nurse may witness the client’s signature.

• Ensure two nurses confirm the information on the blood label: Verifying the client's identity and blood product information by two licensed personnel prevents transfusion errors, such as ABO incompatibility. This is a critical safety measure and a standard facility protocol before starting the transfusion.

• Explain to the client that transfusion reactions are not serious: Minimizing the risks of transfusion reactions is misleading and unsafe. Some reactions can be life-threatening, such as hemolytic or anaphylactic reactions. The nurse should provide accurate education about potential signs and encourage prompt reporting.

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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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Explanation

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