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 hours.

Avoid using lotion or ointment on the newborn's skin.

Answer and Explanation

The Correct Answer is D

Phototherapy is a treatment that uses light to lower the level of bilirubin in the blood of newborns who have jaundice. Jaundice is a condition that causes yellowing of the skin and eyes due to high levels of bilirubin, a waste product that is normally removed by the liver. Phototherapy helps the body break down and eliminate bilirubin through urine and stool¹.
Phototherapy can be done at home or in the hospital, depending on the severity of jaundice and the type of light used. The most common types of light are ﬂuorescent lamps, halogen lamps, or light-emitting diodes (LEDs). The light can be delivered through overhead units, fiber-optic blankets, or fiber-optic pads. The light should cover as much of the newborn's skin as possible, except for the eyes and genitals¹².

The nurse should follow certain guidelines when caring for a newborn who is receiving phototherapy, such
as:
-   Monitor the newborn's temperature, hydration, weight, and urine and stool output regularly
-   Protect the newborn's eyes with eye patches or goggles to prevent eye damage
-   Turn the newborn every 2 to 4 hours to expose diﬀerent parts of the body to the light
-   Feed the newborn frequently to prevent dehydration and promote bilirubin excretion

-   Check the newborn's skin color and bilirubin level periodically to evaluate the eﬀectiveness of
phototherapy
-   Provide emotional support and education to the parents about jaundice and phototherapy
One of the important guidelines is to avoid using lotion or ointment on the newborn's skin during phototherapy. This is because lotion or ointment can block the light from reaching the skin and reduce the eﬀectiveness of phototherapy. Lotion or ointment can also cause skin irritation, rash, or burns if they react with the light. The newborn's skin should be clean and dry before phototherapy¹²³.

The other options are not actions that the nurse should include in the plan of care:
-   a) Keep the newborn supine throughout treatment. This is not correct because keeping the newborn in one position can limit the exposure of diﬀerent parts of the body to the light and reduce the eﬀectiveness of phototherapy. The nurse should turn the newborn every 2 to 4 hours to expose diﬀerent parts of the body to the light¹².
-   b) Dress the newborn in lightweight clothing. This is not correct because dressing the newborn in clothing can block the light from reaching the skin and reduce the eﬀectiveness of phototherapy. The newborn should be undressed except for a diaper during phototherapy¹².
-   c) Measure the newborn's temperature every 8 hours. This is not correct because measuring the newborn's temperature every 8 hours may not be frequent enough to detect any changes in temperature that may occur during phototherapy. Phototherapy can cause overheating or hypothermia in newborns, depending on the type and intensity of light used. The nurse should monitor the newborn's temperature more often, such as every 2 to 4 hours, and adjust the room temperature or use blankets as needed¹².

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Correct Answer is B

Explanation

An ectopic pregnancy is a pregnancy that occurs outside the uterus, usually in the fallopian tube. The most common manifestation of an ectopic pregnancy is sharp pelvic pain, typically on one side. This pain is often described as severe and may be accompanied by shoulder pain or dizziness. The pain occurs because the fallopian tube is not designed to accommodate a growing embryo, leading to stretching and possible rupture of the tube.

Elevated blood pressure is not typically associated with an ectopic pregnancy. Blood pressure changes may occur in other conditions, such as preeclampsia, but it is not a characteristic manifestation of an ectopic pregnancy.

Bright red vaginal discharge is not a typical manifestation of an ectopic pregnancy. Vaginal bleeding may occur, but it is usually darker and more like a menstrual ﬂow. Bright red vaginal discharge may indicate other conditions, such as a threatened miscarriage or a vaginal infection.

A scaphoid abdomen (a concave or sunken appearance of the abdomen) is not a specific manifestation of an ectopic pregnancy. It may be seen in conditions like malnutrition or dehydration, but it is not directly related to an ectopic pregnancy.

A. "Let your toddler see you carrying the baby into the home for the first time." B. "Avoid bringing your toddler to prenatal visits." C. "Require scheduled interactions between the toddler and the baby." D. "Move your toddler to his new bed 2 months before the baby comes home."

Correct Answer is D

Explanation

Preparing a toddler for a new sibling can be challenging, but there are some strategies that can help ease the transition and reduce the risk of jealousy or resentment. One of these strategies is to make any major changes in the toddler's routine or environment well before the baby arrives, such as moving to a new bed, starting preschool, or toilet training. This can help the toddler adjust to the change without feeling displaced or threatened by the baby. It can also prevent the toddler from associating the change with the baby and blaming the baby for it¹².

Moving a toddler to a new bed 2 months before the baby comes home is a good example of this strategy. It gives the toddler enough time to get used to sleeping in a diﬀerent place and feeling comfortable and secure in it. It also avoids making the toddler feel like they are being kicked out of their bed to make room for the baby. The toddler may even feel proud of having a big-kid bed and being more independent¹².

The other options are not appropriate responses by the nurse because they may have negative eﬀects on the toddler's adjustment to the new sibling:

a) "Let your toddler see you carrying the baby into the home for the first time." This is not a good idea because it may make the toddler feel left out or replaced by the baby. The toddler may not understand why they were not with you when you brought the baby home and may feel hurt or angry. A better option is to have someone else carry the baby into the home while you greet your toddler with a hug and a smile. Then, you can introduce your toddler to their new sibling and involve them in welcoming and caring for the baby¹³.

b) "Avoid bringing your toddler to prenatal visits." This is not a good idea because it may make the toddler feel excluded or curious about what is going on. Bringing your toddler to some of your prenatal visits can help them learn more about the baby and feel more connected to them. You can show your toddler pictures of the baby's development, let them hear the baby's heartbeat, or ask them to help you choose clothes or toys for the baby. However, you should also be prepared for your toddler's possible boredom or impatience during long or boring appointments and bring some snacks or activities to keep them entertained¹⁴.

c) "Require scheduled interactions between the toddler and the baby." This is not a good idea because it may make the toddler feel pressured or resentful toward the baby. Forcing your toddler to interact with the baby when they are not ready or interested can backfire and cause more conﬂict or distance between them. A better option is to follow your toddler's cues and let them decide how much and when they want to interact with the baby. You can also praise your toddler for any positive interactions they have with the baby, such as giving them a gentle kiss, sharing a toy, or singing a song¹³.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is B

Explanation

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Correct Answer is D

Explanation

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