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A nurse is caring for a newborn who has jaundice and a new prescription for phototherapy.

Which of the following actions should the nurse take?

A.

Turn the newborn every 4 hr.

B.

Apply hydrating lotion to the newborn's skin prior to treatment.

C.

Close the newborn's eyes before applying eyepatches.

D.

Provide the newborn with 15 mL glucose water after each feeding.

Answer and Explanation

The Correct Answer is C

Choice A rationale:
Turning the newborn every 4 hours is not necessary during phototherapy. The aim of phototherapy is to expose the newborn’s skin to as much light as possible.
Choice B rationale:
Applying hydrating lotion to the newborn’s skin prior to treatment is not recommended. The aim of phototherapy is to expose the newborn’s skin to as much light as possible.
Choice C rationale:
Eye covers should be used to protect the newborn’s eyes from the light during phototherapy.
Choice D rationale:
Providing the newborn with 15 mL glucose water after each feeding is not necessary during phototherapy. The newborn may need to be fed more often to help get rid of the bilirubin in his or her bowel movements.
 


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Related Questions

Correct Answer is B

Explanation

Choice A rationale:
Freezing embryos for future use is a personal decision and not something a nurse should instruct a client to avoid.
Choice B rationale:
In vitro fertilization can result in multiple pregnancies, and reduction of multiple fetuses may be necessary for the health of the mother and the remaining fetuses.
Choice C rationale:
The use of donor oocytes is a personal decision and not something a nurse should instruct a client to avoid.
Choice D rationale:
In in vitro fertilization, sperm is introduced to the egg in a laboratory, not the uterus.

Correct Answer is {"A":{"answers":"B"},"B":{"answers":"B"},"C":{"answers":"C"},"D":{"answers":"B"},"E":{"answers":"B"}}

Explanation

  • Color: Consistent with genetic background

    • Interpretation: B) Sign of potential improvement
    • Rationale: The newborn’s color being consistent with their genetic background indicates a normal adjustment and is not a sign of deterioration. This suggests improvement from the initial condition of acrocyanosis.

  • Axillary Temperature: 36.3°C (97.4°F)

    • Interpretation: B) Sign of potential improvement
    • Rationale: The axillary temperature is within the normal range (36.1°C to 37.2°C), which is a positive sign and suggests that the newborn is maintaining normal body temperature.

  • Reflex Irritability: Cry

    • Interpretation: B) Sign of potential improvement
    • Rationale: A good cry indicates normal reflex irritability and is a positive sign of neurological and overall well-being.

  • Muscle Tone: Flaccid

    • Interpretation: C) Sign of potential worsening condition
    • Rationale: Flaccid muscle tone is concerning as it might indicate a worsening condition or potential neurological issues. It is less typical for muscle tone to be flaccid after the initial adjustment period.

  • Respiration Effort: Good cry

    • Interpretation: B) Sign of potential improvement
    • Rationale: A good cry indicates effective respiration and is a positive sign of the newborn’s respiratory status.

  • Heart Rate: 140/min

    • Interpretation: B) Sign of potential improvement
    • Rationale: The heart rate is within the normal range for newborns (120-160/min), indicating that the cardiovascular system is functioning properly.

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