A nurse is contributing to the plan of care for a newborn who requires phototherapy for hyperbilirubinemia. Which of the following interventions should the nurse recommend including in the plan?
Apply a water-based ointment to the newborn's skin every 4 to 6 hr.
Give the newborn 30 mL of distilled water after each feeding
Reposition the newborn every 2 to 3 hr.
Monitor the newborn's blood glucose level every 2 hr
The Correct Answer is C
A) Incorrect- Applying ointment to the skin during phototherapy is typically avoided as it can interfere with the effectiveness of the therapy.
B) Incorrect- Giving distilled water after feedings is not a typical intervention for phototherapy.
C) Correct - Repositioning the newborn every 2 to 3 hours is important to ensure adequate exposure of the skin to the phototherapy lights and to prevent pressure points.
D) Incorrect- Monitoring blood glucose levels is not a standard intervention during phototherapy unless there are specific indications for doing so.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Rationale:
A. Tachycardia is not a common or direct adverse effect of epidural anesthesia itself. While a rapid heart rate may occur secondary to maternal anxiety or as a compensatory response to hypotension, it is not the primary physiological marker for epidural complications. Heart rate typically remains stable or may decrease slightly as pain is relieved and sympathetic activity is modulated.
B. Fever is a documented potential adverse effect associated with epidural anesthesia, particularly during labor. The exact mechanism is multifactorial, potentially involving altered thermoregulation, reduced heat dissipation due to sympathetic blockade, or a non-infectious inflammatory response. Clinicians must distinguish this pharmacological pyrexia from maternal infection to ensure appropriate neonatal and maternal management following the delivery.
C. Tachypnea, or an increased respiratory rate, is generally not associated with epidural anesthesia. In fact, if the anesthesia level rises too high, it can lead to respiratory depression or a decreased rate due to the blockade of intercostal muscle nerves. Effective epidural analgesia usually promotes a more relaxed, normal breathing pattern by successfully alleviating the physiological stress and hyperventilation caused by acute pain.
D. Hypertension is the opposite of the expected vascular response to epidural anesthesia. The local anesthetic typically causes a sympathetic blockade, leading to peripheral vasodilation and a significant risk of maternal hypotension rather than high blood pressure. Monitoring blood pressure is a critical nursing priority because decreased systemic vascular resistance can compromise placental perfusion and lead to fetal heart rate decelerations.
Correct Answer is A
Explanation
A) Correct- Amoxicillin is a safe and effective antibiotic for treating chlamydia infection in pregnant women.
B) Incorrect - Tetracycline and related antibiotics are often used to treat chlamydia, but they are contraindicated during pregnancy due to potential effects on fetal tooth and bone development. is contraindicated in pregnancy because it can cause fetal tooth discoloration and bone deformities.
C) Incorrect- Metronidazole is used for treating bacterial vaginosis and certain other infections, but it is not the first-line treatment for chlamydia.
D) Incorrect- Acyclovir is used to treat herpes simplex virus infections, not chlamydia.
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