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. Wipe from the outer to the inner canthus after administering the drops: The correct technique is to wipe from the inner to the outer canthus to avoid introducing pathogens into the lacrimal system. Wiping in the wrong direction increases the risk of eye infections.

B. Position the child side-lying on the bed before administering the drops: Eye drops should be administered with the child in a supine or slightly reclined position. Side-lying positioning is more appropriate for ear drops and does not allow proper exposure of the conjunctival sac.

C. Apply pressure to the lacrimal punctum after administering the drops: Pressing the lacrimal punctum (inner corner of the eye) helps prevent systemic absorption of the medication by occluding the tear duct. This increases local efficacy and reduces the risk of systemic side effects, which is especially important in children.

D. Flush the eye with formal saline solution before administering the drops: Flushing with formal saline is unnecessary unless there is debris or discharge. Routine eye drop administration does not require pre-flushing..

A. Request the AP to provide a return demonstration of the task B. Tell the AP to list the steps of the task. C. Ask the family if the AP performed the task correctly. D. Instruct the AP to report back once the task is complete.

Correct Answer is A

Explanation

Rationale:

A. Request the AP to provide a return demonstration of the task: Having the assistive personnel perform a return demonstration allows the nurse to directly observe their technique, ensuring the AP is competent and following proper procedures to prevent complications such as aspiration or infection.

B. Tell the AP to list the steps of the task: While verbalizing steps shows knowledge, it does not guarantee the AP can safely and effectively perform the feeding. Practical demonstration is necessary for skill verification.

C. Ask the family if the AP performed the task correctly: Family feedback may be subjective and is not a reliable method to assess the AP’s competency. The nurse should perform direct assessment.

D. Instruct the AP to report back once the task is complete: Reporting completion alone does not provide information about the quality or safety of the procedure. Direct observation is required to ensure proper technique.

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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?

Nursing Test Bank

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