A nurse is developing a plan of care for a newborn who has hyperbilirubinemia and a prescription for phototherapy. Which of the following interventions should the nurse include?
Check the newborn's temperature every 8 hr.
Apply moisturizing lotion to the newborn's skin every 4 hr.
Give the newborn 1 oz of glucose water every 4 hr.
Reposition the newborn every 2 to 3 hr.
The Correct Answer is D
Choice A rationale:
Checking the newborn's temperature every 8 hours is not directly related to managing hyperbilirubinemia or phototherapy. Monitoring the newborn's temperature is important, but it should be done more frequently, especially during phototherapy, as infants are at risk of developing hypothermia.
Choice B rationale:
Applying moisturizing lotion to the newborn's skin every 4 hours is not a necessary intervention for hyperbilirubinemia or phototherapy. While skin care is important for all newborns, it is not a specific intervention for this condition.
Choice C rationale:
Giving the newborn 1 oz of glucose water every 4 hours is not an appropriate intervention for hyperbilirubinemia. Glucose water is not a recommended treatment for this condition.
Instead, phototherapy helps break down the bilirubin and promote its elimination from the body.
Choice D rationale:
Repositioning the newborn every 2 to 3 hours is the correct intervention. Repositioning helps ensure even exposure of the baby's skin to the phototherapy lights, maximizing its effectiveness in reducing bilirubin levels. Additionally, repositioning prevents pressure ulcers and promotes comfort for the infant during treatment.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A rationale:
Administering oxytocin to the client via intravenous infusion is not appropriate when the nurse notes an umbilical cord protruding through the cervix. The priority is to relieve pressure on the cord to prevent fetal compromise, and administering oxytocin could worsen the situation.
Choice B rationale:
Applying oxygen at 2 L/min via nasal cannula is not the priority when an umbilical cord prolapse is detected. The focus should be on relieving pressure on the cord and changing the client's position to alleviate the compression.
Choice C rationale:
Preparing for insertion of an intrauterine pressure catheter is not appropriate when there is an umbilical cord prolapse. The immediate concern is the potential compromise of fetal blood flow, and addressing the cord prolapse takes precedence over any other interventions.
Choice D rationale:
Assisting the client into the knee-chest position is the correct action when an umbilical cord prolapse is observed during a vaginal exam. This position helps to alleviate pressure on the cord by moving the presenting part of the fetus off the cord and can prevent further fetal distress until more definitive interventions can be performed.
Correct Answer is B
Explanation
Choice A reason:
Nevus flammeus, also known as a port-wine stain, is a flat, pink, red, or purple mark on the skin present at birth. It is a congenital vascular malformation and does not involve swelling that crosses suture lines.
Choice B reason:
Caput succedaneum is the correct diagnosis for swelling that crosses suture lines on a newborn's head, typically associated with a prolonged or difficult vaginal delivery, especially with the use of vacuum extraction.
Choice C reason:
Cephalohematoma is a collection of blood under the periosteum of the cranial bones that does not cross suture lines. It appears soon after birth and is usually caused by birth trauma.
Choice D reason:
Erythema toxicum is a common rash in newborns, presenting as red patches with small white or yellow pustules. It does not cause swelling over the head that crosses suture lines.
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