A nurse is contributing to the plan of care for a newborn who has hyperbilirubinemia and requires phototherapy. Which of the following interventions should the nurse include?

Apply lotion to the newborn's skin twice per day.

Check the newborn's blood glucose every 2 hr.

Swaddle the newborn during the treatment.

Remove the newborn's eye mask during feedings.

Answer and Explanation

The Correct Answer is D

Swaddle the newborn during the treatment. Choice A reason:

Apply lotion to the newborn's skin twice per day. Rationale: The nurse should not apply lotion to the newborn's skin during phototherapy. Phototherapy involves exposing the baby's skin to light to treat hyperbilirubinemia. Applying lotion may interfere with the effectiveness of the treatment or cause adverse reactions.

Choice B reason:

Check the newborn's blood glucose every 2 hours. Rationale: While monitoring the newborn's blood glucose is an essential part of neonatal care, it is not directly related to phototherapy or the treatment of hyperbilirubinemia. Glucose monitoring is typically done to assess for hypoglycemia or other metabolic disturbances.

Choice C reason:

Swaddle the newborn during the treatment. Rationale: The newborn should not be swaddled during phototherapy because it limits exposure of the skin to the phototherapy lights, which is essential for reducing bilirubin levels.

Choice D reason:

Remove the newborn's eye mask during feedings. Rationale:The eye mask is used to protect the newborn's eyes from the bright lights during phototherapy, but it can be removed for feeding. It’s important to ensure that the newborn is fed properly, so removing the mask during feeding is a reasonable and necessary intervention.

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Correct Answer is A

Explanation

Choice A reason: The nurse should include the statement that "This test measures amniotic fluid volume” in the teaching about the biophysical profile (BPP). The rationale for this is that the BPP is a prenatal screening tool that assesses the well-being of the fetus. One of the components of the BPP is the measurement of amniotic fluid volume, which helps to evaluate fetal kidney function and overall fetal health.

Choice B reason:

The nurse should not include the statement about receiving Rh(D) immune globulin prior to the test because it is not directly related to the biophysical profile (BPP). Rh(D) immune globulin is given to Rh-negative pregnant women to prevent hemolytic disease of the newborn (HDN) if the fetus is Rh-positive. While this may be important information during pregnancy, it is not specific to the BPP.

Choice C reason:

The nurse should not include the statement that "This test is used to assess uterine activity” in the teaching about the BPP. The BPP is a test focused on evaluating fetal well-being and not uterine activity. Uterine activity is typically assessed through other methods, such as monitoring contractions during labor.

Choice D reason:

The correct answer is not Choice D. The nurse should not include the statement that "Your bladder needs to be full to perform this test” in the teaching about the BPP. This statement is incorrect because a full bladder is not necessary for the BPP. Instead, the BPP involves the use of ultrasound to assess fetal movements, breathing, muscle tone, and amniotic fluid volume, and a full bladder is not a requirement for this assessment.

A. Hypothermia. B. Hypertension. C. Diaphoresis. D. Mydriasis.

Correct Answer is A

Explanation

Choice A reason:

Hypothermia. Hypothermia refers to a condition where the body temperature drops significantly below the normal range. However, in cases of acute opioid toxicity, the opposite effect is usually observed. Opioids can cause respiratory depression, leading to a decrease in the body's ability to regulate temperature, resulting in hyperthermia, not hypothermia.

Choice B reason:

Hypertension. Acute opioid toxicity typically causes respiratory depression, which can lead to a decrease in blood pressure rather than hypertension. Opioids are central nervous system depressants that slow down the body's vital functions, including heart rate and blood pressure.

Choice C reason:

Diaphoresis. Diaphoresis is the medical term for excessive sweating. While it may occur in some cases of opioid toxicity due to the body's response to stress or increased sympathetic activity, it is not a specific and consistent finding. It is not as characteristic as other symptoms associated with opioid toxicity.

Choice D reason:

Mydriasis. Mydriasis refers to the dilation of the pupils. This is a hallmark sign of opioid toxicity. Opioids can affect the autonomic nervous system, leading to pupillary constriction (miosis) in most cases. However, when opioid toxicity is severe or acute, the pupils may dilate, resulting in mydriasis.

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A nurse is contributing to the plan of care for a newborn who has hyperbilirubinemia and requires phototherapy. Which of the following interventions should the nurse include?

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Naxlex Comprehensive Predictor Exams

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Explanation

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Correct Answer is A

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