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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A reason:
The nurse's priority in this situation is the respiratory rate of 10/min. A respiratory rate of 10 breaths per minute is significantly low and could indicate respiratory depression, especially if the patient is receiving morphine, which is known to depress the respiratory system. This could lead to inadequate oxygenation, potential hypoxia, and other life-threatening complications.
Choice B reason:
Bladder distention may be a concern, but it is not the nurse's priority in this situation. Bladder distention can cause discomfort and urinary retention, but it is not an immediate life- threatening condition compared to potential respiratory depression.
Choice C reason:
A blood pressure of 108/64 mm Hg is within the normal range for an adolescent and may not be the nurse's priority at this time. Although it should be monitored, it does not pose an immediate threat to the patient's life.
Choice D reason:
Nausea and vomiting are common side effects of morphine administration, but they are not the nurse's priority in this situation. While they can cause distress and discomfort to the patient, they are not life-threatening conditions.
Correct Answer is C
Explanation
Choice A reason:
The FACES Scale is a visual pain scale typically used for children who can understand and verbalize their pain intensity. It consists of a series of faces with varying expressions, from smiling to crying, to help the child express their pain level. However, since the client in question is nonverbal and has cognitive and developmental delays, this scale may not be suitable as they might not be able to communicate using this tool effectively.
Choice B reason:
The Numerical Scale involves asking the patient to rate their pain on a scale of 0 to 10, with 0 being no pain and 10 being the worst pain imaginable. While this scale is commonly used for older children and adults, it may not be appropriate for a nonverbal and developmentally delayed 9-year-old client, as they may not understand or be able to use numbers effectively to express their pain.
Choice C reason:
The FLACC pain assessment scale is designed for nonverbal or preverbal individuals, including children and those with cognitive impairments. FLACC stands for Face, Legs, Activity, Cry, and Consolability. Each category is scored from 0 to 2 or 0 to 3, depending on the version used, based on specific observed behaviors. The scores are then totaled to give an overall pain assessment. This scale is particularly suitable for the current client's condition as it focuses on observable behaviors rather than verbal communication.
Choice D reason:
The Visual Analog Scale (VAS) requires the patient to mark a point along a line that represents their pain intensity, with one end indicating no pain and the other end indicating the worst pain. Although this scale is useful for older children and adults, it may not be appropriate for a 9-year-old client with cognitive and developmental delays who might not fully comprehend the concept of the scale.
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