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 B
Explanation
Choice A reason:
Experiences separation anxiety - This is a common behavior seen in toddlers during hospitalization. Being away from their parents or caregivers and being in an unfamiliar environment can lead to feelings of anxiety and distress. Separation anxiety is a natural response for young children who rely on their primary caregivers for comfort and security.
Choice B reason:
Fears a loss of control - Toddlers may feel overwhelmed and fearful when they find themselves in a hospital setting. The loss of control over their daily routines and environment can be frightening for them. They may be unable to understand the reasons behind medical procedures or interventions, further increasing their anxiety.
Choice C reason:
Feels hospitalization is punishment - While some children might have difficulty understanding the reasons for hospitalization, it is less common for them to perceive it as punishment.
Children at this age often lack the cognitive capacity to associate their illness with punishment.
Choice D reason:
Develops body image disturbance - Body image disturbance is not a typical behavior observed in toddlers during hospitalization. This issue is more common in older children or adolescents who may experience changes in their appearance due to medical conditions or treatments.
Correct Answer is C
Explanation
"I should call my provider if I notice thick white discharge in my underwear.”
Choice A reason:
The client stating, "I will need to have this device replaced every 3 years,” is incorrect. Subdermal progesterone contraception devices, such as Nexplanon, can typically last for up to 3 years, not needing replacement within that time frame. The rationale behind this is that these devices release a steady amount of progesterone to prevent pregnancy, and they are designed to be effective for the specified duration.
Choice B reason:
The statement, "This device will protect me from STIs,” in Choice B is incorrect. Subdermal progesterone contraception devices do not provide protection against sexually transmitted infections (STIs). Their primary function is to prevent pregnancy by inhibiting ovulation, thickening cervical mucus, and altering the uterine lining, but they do not offer any defense against STIs. It is essential for the client to understand that barrier methods, such as condoms, are necessary for STI protection.
Choice C reason:
The correct answer, "I should call my provider if I notice thick white discharge in my underwear,” is an accurate statement. Thick white discharge could be indicative of a vaginal infection, such as yeast infection, which might require medical attention. It is crucial for the client to report any changes in vaginal discharge to their healthcare provider for proper evaluation and treatment.
Choice D reason:
The statement in Choice D, "I need to decrease the amount of milk I drink while I have this device,” is incorrect. There is no association between subdermal progesterone contraception devices and milk consumption. The device does not interfere with dairy intake or affect its metabolism. This information is unrelated to the proper use or management of the contraception device.
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