A nurse is evaluating the effectiveness of phototherapy for a post-term infant who has hyperbilirubinemia due to ABO incompatibility with the mother’s blood type O negative and infant’s blood type B positive.

Which of the following findings indicates that phototherapy is effective?

These are normal inflammatory responses to the vaccine.

The tetanus vaccine protects people from the bacteria that cause tetanus, a serious disease that causes muscle stiffness and spasms.

The vaccine stimulates the body’s immune system to produce antibodies against the bacteria.Sometimes, this immune response can cause mild symptoms such as pain, redness, swelling, fever, headache, or tiredness.

These are not signs of an infection or an allergic reaction, but rather the body’s way of building immunity.

Choice A is wrong because an allergic reaction to the vaccine would cause more severe symptoms such as hives, swelling of the face or throat, difficulty breathing, or shock.

These symptoms would usually occur within minutes or hours of getting the vaccine and require immediate medical attention.

Choice C is wrong because these are not signs of an active infection with tetanus.

Tetanus is a rare but potentially fatal disease that causes muscle spasms and paralysis.

It is caused by bacteria that enter the body through wounds or cuts.The symptoms of tetanus usually appear several days or weeks after exposure and include lockjaw, stiffness of the neck and abdomen, difficulty swallowing, fever, sweating, and seizures.

The tetanus vaccine prevents the disease by creating immunity before exposure.

Choice D is wrong because these are not adverse effects of preservatives in the vaccine.

Preservatives are substances that prevent contamination and spoilage of vaccines.The most common preservative used in tetanus vaccines is thimerosal, a mercury-based compound that has been proven to be safe and effective.

There is no evidence that thimerosal causes autism or any other health problems.

Some people may have a sensitivity to thimerosal or other ingredients in the vaccine, but this is very rare and would cause an allergic reaction as described in choice A.

This is a sign of dehydration, which can be caused by phototherapy.Phototherapy increases insensible water loss through the skin and can lead to fluid and electrolyte imbalance in the newborn.The nurse should monitor the newborn’s hydration status, weight, urine output, and serum electrolytes and provide adequate fluid intake.

Choice A is wrong because conjunctivitis is not a common complication of phototherapy.It can be prevented by using eye shields or patches to protect the newborn’s eyes from the light source.

Choice B is wrong because bronze skin discoloration is a rare complication of phototherapy that occurs when the bilirubin level is very high and the skin pigment changes.It is not a priority finding and usually resolves after phototherapy is discontinued.

Choice D is wrong because maculopapular skin rash is a benign side effect of phototherapy that does not require intervention.It usually disappears within a few days after phototherapy is stopped.