A nurse is caring for a newborn who has hyperbilirubinemia and is receiving phototherapy.

Which of the following interventions should the nurse implement?

Apply sunscreen to the newborn’s skin before placing under the lights.

Cover the newborn’s eyes with eye shields or patches.

Turn off the phototherapy lights during feedings.

Keep the newborn fully clothed to prevent heat loss.

Answer and Explanation

The Correct Answer is B

Cover the newborn’s eyes with eye shields or patches. This is because phototherapy can cause eye damage and irritation to the newborn, so the eyes should be protected while the lights are on.

Some possible explanations for the other choices are:

• Choice A is wrong because applying sunscreen to the newborn’s skin before placing under the lights can interfere with the effectiveness of phototherapy and increase the risk of skin irritation and infection.

• Choice C is wrong because turning off the phototherapy lights during feedings can reduce the exposure time and delay the clearance of bilirubin from the newborn’s blood.

• Choice D is wrong because keeping the newborn fully clothed to prevent heat loss can also interfere with the effectiveness of phototherapy and increase the risk of overheating and dehydration.

Normal ranges for bilirubin levels in newborns vary depending on the age, gestational age, and risk factors of the newborn. Generally, a total serum bilirubin level of less than 12 mg/dL (205 micromol/L) is considered normal for term newborns in the first week of life. Phototherapy is usually indicated when the total serum bilirubin level exceeds 15 mg/dL (257 micromol/L) for term newborns or 10 mg/dL (171 micromol/L) for preterm newborns.

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Correct Answer is A

Explanation

Place the newborn on the mother’s chest after delivery.This is because skin-to-skin contact between mother and baby promotes bonding and attachment, which are essential for the baby’s emotional and psychological development.Skin-to-skin contact also helps regulate the baby’s body temperature, heart rate, breathing and blood sugar levels.

Choice B is wrong because wrapping the newborn in a blanket reduces the skin-to-skin contact and may interfere with the bonding process.The father can also bond with the baby by holding him or her against his own skin.

Choice C is wrong because placing the newborn in an isolette separates the baby from the mother and prevents close interaction and communication.The baby may feel insecure and isolated in an isolette.

Choice D is wrong because dressing the newborn in a gown and hat also reduces the skin-to-skin contact and may delay the initiation of breastfeeding.The baby may also lose more heat through clothing than through direct contact with the mother’s body.

A. Administer hepatitis B immune globulin (HBIG) to the newborn within 12 hours of birth. B. Monitor the newborn for signs of jaundice and anemia. C. Obtain a blood sample from the newborn for blood typing and crossmatching. D. Prepare the newborn for exchange transfusion with type O negative blood.

Correct Answer is B

Explanation

Monitor the newborn for signs of jaundice and anemia.

This is because the newborn has a positive Coombs test, which means that there are antibodies against the newborn’s red blood cells (RBCs) in the blood.

These antibodies can cause hemolysis (destruction) of the RBCs, leading to jaundice (yellowing of the skin and eyes due to high bilirubin levels) and anemia (low RBC count and hemoglobin levels).The most likely cause of the positive Coombs test in this case is ABO incompatibility, which occurs when the mother has type O blood and the newborn has type A or B blood.

Choice A is wrong because administering hepatitis B immune globulin (HBIG) to the newborn within 12 hours of birth is indicated for newborns whose mothers are positive for hepatitis B surface antigen (HBsAg), which is not the case here.

Choice C is wrong because obtaining a blood sample from the newborn for blood typing and crossmatching is not necessary, as the newborn’s blood type is already known to be A positive.

Choice D is wrong because preparing the newborn for exchange transfusion with type O negative blood is a treatment option for severe cases of hemolytic disease of the newborn (HDN), which is not evident in this scenario.Exchange transfusion involves replacing the newborn’s blood with donor blood to remove antibodies and bilirubin.

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A nurse is caring for a newborn who has hyperbilirubinemia and is receiving phototherapy. Which of the following interventions should the nurse implement?

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A nurse is caring for a newborn who has hyperbilirubinemia and is receiving phototherapy.

Which of the following interventions should the nurse implement?