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
A) Incorrect- While notifying the provider might be necessary, addressing bladder distention takes precedence in this scenario.
B) Incorrect- Administering an analgesic might be indicated for pain relief, but addressing bladder distention is the priority.
C) Correct - Assisting the client to empty her bladder is the first action to take. A full bladder can prevent the uterus from contracting properly and can lead to excessive bleeding.
D) Incorrect- Monitoring perineal pads for clots is important but not the first action to take when bladder distention is present.
Correct Answer is A
Explanation
A) Correct - Encouraging the client to void often is important, as a full bladder can increase discomfort and interfere with labor progress.
B) Incorrect- Remaining awake between contractions might not directly address pain management strategies.
C) Incorrect- Position changes can help with pain management, so minimizing them would not be appropriate.
D) Incorrect- The presence of a support person is often encouraged during labor, and there is no need to limit their time in the room.
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