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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale:
Yellowed sclera in a newborn could indicate jaundice, which should be reported to the provider.
Choice B rationale:
Stooling after each breastfeeding is normal for a newborn.
Choice C rationale:
Intermittent crossing of eyes is common in newborns and usually resolves by 3 months of age.
Choice D rationale:
Voiding eight to ten times per day is normal for a newborn.
Correct Answer is ["B","C","D"]
Explanation
Choice A rationale:
Peripheral edema is common in the postpartum period and does not require immediate follow-up.
Choice B rationale:
Lateral deviation of the uterus could indicate a full bladder, which requires immediate follow-up.
Choice C rationale:
Large amount of lochia rubra 8 hours postpartum could indicate postpartum hemorrhage, which requires immediate follow-up.
Choice D rationale:
A soft uterine tone could indicate uterine atony, a cause of postpartum hemorrhage, which requires immediate follow-up.
Choice E rationale:
Soft breasts are normal in the immediate postpartum period and do not require immediate follow-up.
Choice F rationale:
Deep tendon reflexes of 1+ are normal and do not require immediate follow-up.
Choice G rationale:
A pain rating of 3 on a scale of 0 to 10 is manageable and does not require immediate follow-up.
Choice H rationale:
Blood pressure of 136/86 mm Hg is slightly elevated but does not require immediate follow-up unless there are other signs of preeclampsia.
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