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?

Turn the newborn every 4 hr.

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

Close the newborn's eyes before applying eyepatches.

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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Correct Answer is A

Explanation

Choice A rationale:
The client is experiencing postpartum hemorrhage, and the nurse should first collect hemoglobin and hematocrit levels to assess the extent of blood loss.
Choice B rationale:
Inserting an indwelling urinary catheter is not the immediate priority. It may be done later to monitor fluid balance.
Choice C rationale:
Administering oxygen is important, but it’s not the first action. The nurse needs to assess the extent of blood loss first.
Choice D rationale:
Preparing the client to receive a plasma expander is important, but it’s not the first action. The nurse needs to assess the extent of blood loss first.

A. "This medication increases cardiac output.”. B. "This medication prevents seizures.”. C. "This medication stabilizes the fetal heart rate.”. D. "This medication improves tissue perfusion.”.

Correct Answer is B

Explanation

Choice A rationale:
Magnesium sulfate does not increase cardiac output. It is a central nervous system depressant and muscle relaxant.
Choice B rationale:
Magnesium sulfate is given to clients with preeclampsia to prevent seizures, which can be a complication of this condition.
Choice C rationale:
Magnesium sulfate does not directly stabilize the fetal heart rate. Its primary use in preeclampsia is seizure prevention.
Choice D rationale:
While magnesium sulfate can cause vasodilation, which could improve tissue perfusion, its primary use in preeclampsia is to prevent seizures.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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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?