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) Incorrect - The umbilical area is not a typical location for auscultating fetal heart tones.
B) Incorrect - The suprapubic area is not a common location for auscultating fetal heart tones.
C) Correct - At 12 weeks of gestation, the nurse would typically auscultate the fetal heart tones above the left iliac crest, which is in the lower abdomen. This is where the uterus is located at this stage of pregnancy.
D) Incorrect - Auscultating below the liver border on the right abdomen is not a standard practice for fetal heart tone assessment.
Correct Answer is C
Explanation
A) Incorrect- Cleansing the perineum with povidone-iodine is not relevant to the collection process.
B) Incorrect- The 24-hour collection should start with the first-morning urination, not with any random urination.
C) Correct - Recording the time on the collection container for any missed urine specimens is important for accurate measurement.
D) Incorrect- Stool should not be added to the urine collection container, but this is not the most important point to emphasize in this teaching.
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