A nurse is caring for a newborn who is receiving phototherapy treatment. Which of the following actions should the nurse take?
Place the newborn in the prone position.
Offer glucose water after each feeding.
Apply lotion to the newborn's exposed skin.
Cover the newborn's eyes with a mask.
The Correct Answer is D
A. Place the newborn in the prone position: The supine position is recommended for newborns to reduce the risk of sudden infant death syndrome (SIDS). Phototherapy does not change this guideline, and the baby should be placed on their back.
B. Offer glucose water after each feeding: Glucose water is not recommended as a supplement. Breast milk or formula provides sufficient nutrition and hydration. The focus should be on maintaining regular feedings to support bilirubin excretion.
C. Apply lotion to the newborn's exposed skin: Lotions and ointments should be avoided during phototherapy because they can cause skin irritation or even burns when exposed to the phototherapy lights.
D. Cover the newborn's eyes with a mask: The eyes must be protected during phototherapy to prevent retinal damage from the intense light exposure. A properly fitted eye mask should be used and checked regularly for correct placement.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Bradypnea: Magnesium sulfate toxicity depresses the central nervous system, leading to respiratory depression such as bradypnea. This is a critical sign requiring immediate intervention, as respiratory rates below 12 breaths per minute can be life-threatening.
B. Tremors: Tremors are typically associated with hypomagnesemia or withdrawal states, not magnesium toxicity. Magnesium toxicity causes muscle weakness and diminished reflexes rather than increased neuromuscular activity.
C. Insomnia: Insomnia is not a recognized symptom of magnesium toxicity. In contrast, elevated magnesium levels tend to cause sedation, lethargy, and decreased mental alertness.
D. Hypertension: Magnesium sulfate can actually lower blood pressure due to its vasodilatory effects. Hypertension would be inconsistent with toxicity and more commonly seen in preeclampsia before magnesium is administered.
Correct Answer is D
Explanation
A. "The client was intubated without complications.": While relevant to the surgical process, this detail is more critical in the operating or PACU setting and less essential for ongoing post-op care unless complications occurred.
B. "The client is a member of the board of directors.": This is not clinically relevant and violates the client’s confidentiality by sharing unnecessary personal information.
C. "There was a total of 10 sponges used during the procedure.": Sponge count is important intraoperatively, but it is not typically necessary in a hand-off unless a count discrepancy occurred.
D. "The estimated blood loss was 250 milliliters.": This is clinically relevant and necessary for postoperative monitoring. It informs the receiving nurse about potential volume loss and the need to monitor for signs of hypovolemia.
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