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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. Platelets 170,000/mm³ is a normal platelet count in pregnancy. The normal range for platelets in pregnancy is 150,000 to 450,000/mm³⁷⁸.
B. This HbA1c level indicates good control of blood glucose levels over the past 2-3 months. For a pregnant woman with type 1 diabetes, a target HbA1c of less than 6-7% is often recommended to reduce the risk of complications.
C. This blood urea nitrogen (BUN) level is elevated. Normal BUN levels typically range from 7 to 20 mg/dL. Elevated BUN may indicate renal impairment, which can be a concern for a pregnant woman with type 1 diabetes, as it could suggest developing diabetic nephropathy or other kidney-related issues.
D. Hct 34% is a normal hematocrit level in pregnancy. The normal range for hematocrit in pregnancy is 30% to 36%.
Correct Answer is A
Explanation
A client who is in labor and reports an urge to have a bowel movement during contractions may be experiencing the transition phase of labor, which is the last and most intense part of the first stage of labor¹². The transition phase occurs when the cervix dilates from 8 to 10 cm and the baby descends into the birth canal¹². The pressure of the baby's head on the rectum can cause a sensation of needing to defecate¹². The transition phase can last from 15 minutes to an hour or more, and it can be accompanied by other signs, such as strong, regular, and painful contractions lasting 60 to 90 seconds; increased bloody show; nausea and vomiting; shaking and shivering; and emotional changes such as irritability, anxiety, or excitement¹²³.
The nurse should reassess the client who reports an urge to have a bowel movement during contractions because this may indicate that the client is close to delivering the baby and needs to be prepared for the second stage of labor, which involves pushing and giving birth¹². The nurse should check the client's cervical dilation, fetal heart rate, and maternal vital signs, and notify the provider if the client is fully dilated or shows signs of fetal or maternal distress¹². The nurse should also support the client's coping strategies, such as breathing techniques, relaxation methods, or pain relief options, and encourage the client not to push until instructed by the provider¹².
b) A sense of excitement and warm, flushed skin are not signs that require reassessment by the nurse. These are normal emotional and physiological responses to labor that reflect increased adrenaline levels and blood flow¹⁴. They do not indicate any complications or imminent delivery.
c) Progressive sacral discomfort during contractions is not a sign that requires reassessment by the nurse. This is a common symptom of labor that results from the pressure of the baby's head on the sacrum and nerves in the lower back¹⁴. It does not indicate any problems or imminent delivery.
d) Intense contractions lasting 45 to 60 seconds are not signs that require reassessment by the nurse. These are typical characteristics of active labor contractions, which occur when the cervix dilates from 4 to 8 cm¹⁴. They do not indicate any complications or imminent delivery.
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