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 A
Explanation
A) Correct- Feeling the baby's swallowing during breastfeeding indicates that the baby is effectively transferring milk from the breast. It suggests that the baby is latched on correctly and is receiving milk.
B) Incorrect- Moderate tenderness during breastfeeding is common initially, but it should not be persistent or severe.
C) Incorrect- While bowel movements are important, having at least one bowel movement every day is not necessarily an indicator of effective breastfeeding.
D) Incorrect- While wet diapers are important to ensure adequate hydration, having at least six wet diapers every day is not the primary sign of effective breastfeeding.
Correct Answer is B
Explanation
A) Incorrect- Urinary retention can be a concern but is not as immediately life-threatening as respiratory depression.
B) Correct - A respiratory rate of 11/min is significantly lower than the normal range and indicates respiratory depression, which can be life-threatening. It requires immediate attention.
C) Incorrect- A blood pressure of 105/62 mm Hg is within a normal range for an adolescent and does not require immediate intervention.
D) Incorrect- Blurred vision might be a side effect of medications, but respiratory depression takes priority due to its potential to lead to serious complications.
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