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 A
Explanation
The correct answer is: A. Hemoglobin 12 g/dL.
Choice A reason:
Hemoglobin levels in newborns are expected to be significantly higher than in adults due to the physiological adaptation to life outside the womb. The normal range for a newborn’s hemoglobin is approximately 14 to 24 g/dL1234. A level of 12 g/dL is below the expected range and could indicate anemia or other underlying conditions that may require further investigation and intervention by the healthcare provider.
Choice B reason:
The glucose level in a newborn can vary, especially within the first few hours after birth. Normal blood glucose levels for a newborn 1 to 2 hours old can be as low as 25 mg/dL and can rise to adult levels (60-100 mg/dL) within the first few days5. A glucose level of 50 mg/dL in a 24-hour-old newborn falls within the acceptable range and would not typically require reporting to the provider unless accompanied by symptoms of hypoglycemia.
Choice C reason:
Bilirubin levels in newborns can be elevated due to the normal breakdown of fetal hemoglobin as the baby’s liver matures. Normal bilirubin levels for a newborn can range from 1.0 to 12.0 mg/dL6. A bilirubin level of 4 mg/dL is within the normal range for a 24-hour-old newborn and is not typically a cause for concern unless there are signs of jaundice or other symptoms.
Choice D reason:
The normal platelet count for a newborn ranges from 150,000 to 450,000/mm³7. A platelet count of 200,000/mm³ is well within the normal range for a newborn and would not need to be reported to the healthcare provider.
Correct Answer is C
Explanation
Choice A rationale:
Keeping the newborn dressed while receiving phototherapy is not recommended because the baby's skin needs to be exposed to the light to effectively treat hyperbilirubinemia. Direct exposure to light helps break down the excess bilirubin in the baby's blood, leading to its excretion.
Choice B rationale:
Applying lotion to the skin twice daily is contraindicated during phototherapy. Lotions and creams can block the light from reaching the skin and hinder the therapeutic effects of the phototherapy. The baby's skin should remain exposed to the light for optimal treatment.
Choice C rationale:
Maintaining an eye mask over the newborn's eyes is essential during phototherapy. The eyes are sensitive to light, and prolonged exposure to the phototherapy light can lead to eye damage. Using an eye mask protects the baby's eyes while allowing the rest of the body to receive the necessary light treatment.
Choice D rationale:
Maintaining the phototherapy during blood draws is crucial to ensure continuous treatment of hyperbilirubinemia. Interrupting the phototherapy during blood draws might result in the rebound of bilirubin levels, which can be harmful to the baby.
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