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.
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Related Questions
Correct Answer is C
Explanation
A.This would be appropriate if the fetus were in a breech presentation.
B.This is incorrect because the fetal back is in the lower left quadrant, not the upper quadrant.
C.In the Left Occipitoanterior (LOA) Position, the fetal occiput (back of the head) is facing the mother’s left side and anteriorly (toward the front of the uterus). The fetal back will be on the left side of the maternal abdomen, making the PMI in the left lower quadrant. The best location to place the fetal monitor is over the fetal back, closest to the head. Since the fetus is cephalic (head down) in LOA position, the heart sounds are heard in the left lower quadrant.
D.This would be appropriate if the fetus were in a right occipitoanterior (ROA) position, but in LOA, the back is on the left.
Correct Answer is C
Explanation
"You can expect your breasts to be firm and tender 3 to 5 days after delivery." Postpartum care includes education on physical changes that occur after delivery. It is important for the nurse to inform the client that breast engorgement is a common occurrence and may result in firm, tender breasts 3 to 5 days after delivery. The nurse should also encourage the client to use a breast pump or express milk by hand to relieve discomfort. It is not advisable for the client to rely solely on breastfeeding as a form of birth control, so the nurse should educate the client on the importance of using contraception. Postpartum bleeding is typically bright red
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