A nurse is planning care for a full-term newborn who is receiving phototherapy. Which of the following actions should the nurse include in the plan of care?
Keep the newborn supine throughout treatment.
Dress the newborn in lightweight clothing.
Measure the newborn's temperature every 8 hr.
Avoid using lotion or ointment on the newborn's skin.
The Correct Answer is D
A. It is essential to regularly reposition the newborn (every 2-3 hours) to ensure even exposure to the phototherapy light and to prevent pressure sores. Keeping the newborn supine throughout the treatment is not recommended.
B. The newborn should be undressed, except for a diaper, during phototherapy to maximize skin exposure to the light. Lightweight clothing can reduce the effectiveness of the treatment.
C. Temperature monitoring should be more frequent than every 8 hours. Phototherapy can cause fluctuations in the newborn's temperature, including overheating or hypothermia, so checking every 2-4 hours is generally recommended.
D. Lotions or ointments should not be applied to the newborn's skin during phototherapy because they can absorb heat, potentially leading to burns or skin irritation. Phototherapy can dry out the skin, but moisturizing treatments should be avoided during the therapy itself.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
: "This test will detect the presence of Rh-positive antibodies in your blood." The indirect Coombs' test is a blood test that is used to detect the presence of antibodies against red blood cells in a person's blood. It is commonly used to determine whether a pregnant woman is at risk of hemolytic disease of the newborn (HDN), a condition in which the mother's antibodies attack the red blood cells of the fetus.
Choice A is incorrect because the amount of amniotic fluid around the fetus is measured by an amniocentesis, not a Coombs' test. Choice B is incorrect because ultrasound studies blood flow in the fetus and placenta using sound waves, not ultrasound waves. Choice D is incorrect because hypoglycemia after birth is not related to the Coombs' test, but may be related to other tests, such as a blood glucose test.
Correct Answer is D
Explanation
The nurse should explain to the client that amniocentesis is a diagnostic test that is performed between 15 and 20 weeks of gestation to determine if the fetus has genetic or congenital disorders. While the procedure can also determine the sex of the fetus, this is not typically the primary reason for the test. The nurse should clarify any misconceptions the client has about the procedure and provide education on its purpose, risks, and benefits. The nurse should also assess the client's understanding of the information provided and address any questions or concerns the client may have.
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