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 A
Explanation
After a client with eclampsia experiences a convulsion, the nurse should immediately prioritize ensuring adequate oxygenation for the client. Administering oxygen via a face mask at 10 L/min helps to increase oxygen levels and support the client's respiratory function. This intervention addresses the immediate need for oxygenation and helps support the client's respiratory function following a convulsion associated with eclampsia. Prompt and appropriate management of eclampsia is crucial to ensure the safety and well-being of both the mother and the fetus.
Option b) Placing the client in a Trendelenburg position (head down and legs elevated) is not appropriate in this situation. It can potentially worsen blood flow to the brain and may lead to increased intracranial pressure.
Option c) Assisting the client to void may be important for monitoring urine output, but it is not the immediate priority following a convulsion. The client's safety and stabilization take precedence.
Option d) Giving calcium gluconate is not indicated for the management of eclampsia. Calcium gluconate is used to treat hypocalcemia or as an antidote for certain medication toxicities. The primary treatment for eclampsia involves controlling and preventing seizures, which is not achieved through calcium gluconate administration.
Correct Answer is B
Explanation
Among the given options, the client who has hyperemesis gravidarum and a sodium level of 110 mEq/L should be assessed first. Hyperemesis gravidarum is a condition characterized by severe and persistent vomiting during pregnancy, leading to dehydration and electrolyte imbalances. A sodium level of 110 mEq/L indicates hyponatremia, which is an abnormally low level of sodium in the blood.
Hyponatremia can lead to serious complications, including neurological symptoms such as confusion, seizures, and coma. Prompt assessment and intervention are necessary to correct the electrolyte imbalance and prevent further complications.
Option a) A client with preeclampsia and a creatinine level of 1.1 mg/dL should be monitored closely, as elevated creatinine levels can indicate impaired kidney function. However, in this scenario, the client with hyperemesis gravidarum and severe hyponatremia requires more immediate attention due to the potential for neurological complications.
Option c) A client with diabetes mellitus and an HbA1C of 5.8% may require further management and monitoring, but it does not present an immediate risk or urgency compared to the client with hyperemesis gravidarum and severe hyponatremia.
Option d) A client with placenta previa and a hematocrit of 35% may need close monitoring for potential bleeding, but it does not pose an immediate threat compared to the client with hyperemesis gravidarum and severe hyponatremia.
Therefore, the nurse should assess the client who has hyperemesis gravidarum and a sodium level of 110 mEq/L as the first priority due to the risk of complications associated with severe hyponatremia.
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