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 C
Explanation
The correct answer is choice C: "I will tip the nipple so air is present as my baby sucks.”
Choice A rationale:
The parent's statement in choice A, "I will keep my baby's head elevated while he is feeding,” indicates an understanding of proper bottle feeding techniques. Keeping the baby's head slightly elevated can help prevent choking and aspiration during feedings. This is a correct statement, and no further instruction is needed in this regard.
Choice B rationale:
The parent's statement in choice B, "I will allow my baby to burp several times during each feeding,” also demonstrates knowledge of appropriate bottle feeding practices. Burping the baby during and after feedings helps release swallowed air, reducing the likelihood of excessive gas and discomfort. This statement is correct, and no additional instruction is required.
Choice C rationale:
Choice C is the incorrect statement because tipping the nipple to introduce air while the baby sucks is not a recommended practice. In fact, it can lead to an increased intake of air, potentially causing gas, discomfort, and colic in the baby. Therefore, further instruction is needed to correct this misconception.
Choice D Rationale:
Choice D is not directly related to the need for further instruction in bottle feeding techniques and is not addressed in the explanation.
Correct Answer is C
Explanation
Choice A rationale:
Monitoring fluid intake is important for any newborn, but it is not the priority intervention for a small for gestational age (SGA) newborn. SGA infants are at risk of hypoglycemia due to limited glycogen stores, and monitoring blood glucose levels is crucial in identifying and managing hypoglycemia.
Choice B rationale:
Monitoring axillary temperature is essential for all newborns to assess their thermoregulation. However, it is not the priority intervention for an SGA newborn. Hypoglycemia is a more immediate concern and must be addressed promptly.
Choice C rationale:
Monitoring blood glucose levels is the priority intervention for an SGA newborn. As mentioned earlier, SGA infants are at higher risk of hypoglycemia, which can lead to serious complications if not managed appropriately. By monitoring blood glucose levels, the nurse can detect and address hypoglycemia early.
Choice D rationale:
Monitoring weight is important for tracking the growth and development of the newborn, but it is not the priority intervention in this scenario. The immediate concern for an SGA newborn is their blood glucose levels.
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