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.

Answer and Explanation

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.

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Correct Answer is A

Explanation

Choice A rationale:

Before an amniocentesis, it is essential for the client to empty their bladder. A full bladder can interfere with the procedure, as it may obstruct the needle's entry into the uterus and increase the risk of accidental bladder puncture.

Choice B rationale:

Nothing by mouth (NPO) for 4 hours is not necessary for an amniocentesis. It is a relatively simple and quick procedure that does not require fasting.

Choice C rationale:

Ingesting 3 liters of water is not indicated before an amniocentesis. While some ultrasound examinations may require a full bladder, this is not the case for an amniocentesis.

Choice D rationale:

Nipple stimulation is not relevant or necessary before an amniocentesis. Nipple stimulation can trigger uterine contractions, which might be undesirable before the procedure, especially if the client is not in labor.

A. Assess the client's blood pressure. B. Assess the fetal heart rate pattern. C. Take the client's temperature. D. Prepare for a c-section.

Correct Answer is B

Explanation

Assess the fetal heart rate pattern.

Choice B rationale:

When a laboring client's membranes have just ruptured, the nurse's next action should be to assess the fetal heart rate pattern. Rupture of membranes can lead to changes in amniotic fluid, which can affect the fetal environment and potentially cause fetal distress. By assessing the fetal heart rate pattern, the nurse can determine if the baby is tolerating the labor process well or if there are signs of fetal compromise that require further intervention.

Choice A rationale:

While assessing the client's blood pressure (Choice A) is important during labor, it is not the immediate next action when the membranes have ruptured.

Choice C rationale:

Taking the client's temperature (Choice C) is also important, but it is not the priority action when the membranes have ruptured.

Choice D rationale:

Preparing for a c-section (Choice D) is not the initial action unless there are specific indications for an emergency cesarean section. Assessing the fetal heart rate is more critical at this stage.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Prior to an amniocentesis, what action by the client will need to be completed?

Correct Answer is A

Explanation

A laboring client's membranes have just ruptured. What is the nurse's next action?

Correct Answer is B

Explanation

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