A nurse is planning care for a newborn who has hyperbilirubinemia and is to receive phototherapy. Which of the following interventions should the nurse include?

Clothe the newborn in light cotton.

Check the newborn's temperature every 8 hr.

Administer 120 mL (4 oz) of water between feedings.

Place the newborn 45 cm (18 in) from the light source.

Answer and Explanation

The Correct Answer is D

- A. Clothing the newborn in light cotton is not recommended because it can block the light from reaching the skin, which is necessary for the treatment of hyperbilirubinemia through phototherapy.
- B. Checking the newborn's temperature every 8 hours is not frequent enough; during phototherapy, it is important to monitor the newborn's temperature more frequently to ensure they do not become too cold or too warm as a result of the therapy.
- C. Administering water between feedings is not recommended as it can interfere with the newborn's feeding schedule and nutrition; breast milk or formula provides adequate hydration unless otherwise indicated by a healthcare provider.
- D. Placing the newborn 45 cm (18 in) from the light source is the correct intervention. This distance allows for optimal exposure to the light while ensuring the safety and comfort of the newborn, as recommended in clinical guidelines for effective phototherapy.

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Correct Answer is C

Explanation

A: Tucking the chin while swallowing can actually help prevent aspiration in clients with dysphagia, as it narrows the tracheal opening and helps direct food away from the airway.

B: Sitting upright during meals is a recommended practice to reduce the risk of aspiration. It allows gravity to assist with the movement of food, reducing the likelihood of it entering the airway.

C: Pocketing food on one side of the mouth can be a sign of reduced sensation or motor control on that side, often a result of a stroke. This can lead to unnoticed accumulation of food which may then be aspirated.

D: A cough reflex is a protective mechanism against aspiration. If food enters the airway, the cough reflex should trigger, helping to expel the food from the airway and prevent aspiration.

A. Head compression B. Fetal hypoxia C. Abruptio placentae D. Postmaturity

Correct Answer is A

Explanation

A. Early decelerations are typically benign and occur due to head compression during

contractions. They mirror the uterine contraction pattern and are not usually associated with fetal compromise.

B. Fetal hypoxia is not typically associated with early decelerations, as they are considered a normal response to head compression during labor.

C. Abruptio placentae refers to the premature separation of the placenta from the uterine wall and is not directly related to early decelerations.

D. Postmaturity refers to a pregnancy that extends beyond 42 weeks gestation and is not directly related to early decelerations.

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