A nurse is caring for an infant who is receiving phototherapy. Which of the following findings requires intervention by the nurse?
The mother applies lotion to the newborn's skin.
The newborn's stools increase in number.
A pink rash appears on the newborn's trunk.
The newborn's eyes are covered with a mask.
The Correct Answer is A
Choice A reason: The mother applying lotion to the newborn's skin requires intervention by the nurse, because it can interfere with the effectiveness of phototherapy and increase the risk of thermal injury. The nurse should instruct the mother to avoid using any lotions, creams, or oils on the newborn's skin during phototherapy.
Choice B reason: The newborn's stools increasing in number does not require intervention by the nurse, because it is a normal and expected outcome of phototherapy. Phototherapy can increase the breakdown and excretion of bilirubin, which can result in more frequent and loose stools.
Choice C reason: A pink rash appearing on the newborn's trunk does not require intervention by the nurse, because it is a common and harmless side effect of phototherapy. The rash usually disappears within a few days after phototherapy is discontinued.
Choice D reason: The newborn's eyes being covered with a mask does not require intervention by the nurse, because it is a standard and essential precaution for phototherapy. The mask protects the newborn's eyes from the harmful effects of the light, such as corneal damage or retinal injury.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["200"]
Explanation
The correct answer is 200 mL/hr.
To calculate the IV rate, the nurse should use the following formula:
IV rate (mL/hr) = (Volume to be infused (mL) / Time of infusion (hr)) x Drop factor (gtt/mL)
In this case, the volume to be infused is 100 mL, the time of infusion is 0.5 hr (30 min), and the drop factor is 1 gtt/mL (assuming the IV pump is calibrated in mL/hr). Therefore, the formula becomes:
IV rate (mL/hr) = (100 mL / 0.5 hr) x 1 gtt/mL
IV rate (mL/hr) = 200 mL/hr
The nurse should round the answer to the nearest whole number, which is 200 mL/hr. The nurse should use a leading zero if the answer is less than 1, which is not the case here. The nurse should not use a trailing zero, which means 200 mL/hr and not 200.0 mL/hr.
Correct Answer is C
Explanation
Choice A reason: Glipizide is not an appropriate medication for the client, because it is a sulfonylurea that can cross the placenta and cause fetal hypoglycemia, hyperinsulinemia, and macrosomia. Glipizide is contraindicated in pregnancy.
Choice B reason: Acarbose is not an appropriate medication for the client, because it is an alpha-glucosidase inhibitor that can cause gastrointestinal side effects, such as flatulence, diarrhea, and abdominal pain. Acarbose is not recommended in pregnancy.
Choice C reason: Glyburide is an appropriate medication for the client, because it is a sulfonylurea that has a low placental transfer and a minimal risk of fetal hypoglycemia. Glyburide is considered safe and effective in pregnancy.
Choice D reason: Repaglinide is not an appropriate medication for the client, because it is a meglitinide that can cross the placenta and cause fetal hypoglycemia and teratogenic effects. Repaglinide is contraindicated in pregnancy.
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