A nurse is caring for a newborn with jaundice who has a new prescription for phototherapy. What actions should the nurse take?
Apply hydrating lotion to the newborn’s skin prior to treatment.
Provide the newborn with 15 mL glucose water after each feeding.
Turn the newborn every 4 hours.
Close the newborn’s eyes before applying eyepatches.
The Correct Answer is D
Choice A rationale
Applying hydrating lotion to the newborn’s skin prior to treatment is not recommended. The goal of phototherapy is to expose the newborn’s skin to light, and applying lotion could potentially interfere with the effectiveness of the treatment.
Choice B rationale
Providing the newborn with 15 mL glucose water after each feeding is not a standard part of phototherapy treatment. The newborn should continue to receive regular feedings, but additional glucose water is not typically necessary.
Choice C rationale
Turning the newborn every 4 hours is not sufficient during phototherapy. The newborn should be repositioned frequently, ideally every 2-3 hours, to expose all areas of the skin to the light.
Choice D rationale
It is important to protect the newborn’s eyes during phototherapy to prevent damage from the light. Therefore, the newborn’s eyes should be covered with special patches whenever the lights are on.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale
Irregular contractions of 10 to 20 seconds in duration that are not felt by the client during a nonstress test may indicate a need for further diagnostic testing. These could be Braxton Hicks contractions, which are normal, but if they become regular and increase in intensity, they could indicate preterm labor.
Choice B rationale
An increase in fetal heart rate to 150/min above the baseline of 140/min lasting 10 seconds in response to fetal movement within a 40-min testing period is a normal finding on a nonstress test. This is known as a reactive nonstress test and indicates that the fetus is well-oxygenated.
Choice C rationale
No late decelerations in the fetal heart rate noted with three uterine contractions of 60 seconds in duration within a 10-min testing period is a normal finding on a nonstress test. Late decelerations can indicate fetal hypoxia.
Choice D rationale
Three fetal movements perceived by the client in a 20-min testing period is a normal finding on a nonstress test. Fetal movement is a positive sign of fetal well-being.
Correct Answer is B
Explanation
Choice A rationale
The position of the uterine fundus is not directly related to the client’s ability to void effectively.
Choice B rationale
A client urinating 30 ml/h indicates that the client is able to void effectively. This is the minimum acceptable urine output in an adult client.
Choice C rationale
Not feeling the urge to urinate could indicate a problem such as urinary retention.
Choice D rationale
A distended bladder upon palpation could indicate urinary retention, which means the client is not voiding effectively.
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