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 D

Explanation

A. A blood pressure of 94/68 mm Hg is within the normal range for a 7-year-old child and may indicate compensated dehydration rather than severe dehydration.

B. A urinary output of 30 mL/hr is insufficient and may indicate dehydration, but it does not specifically indicate severe dehydration.

C. A respiratory rate of 24/min is within the normal range for a 7-year-old child and is not specifically indicative of severe dehydration.

D. Tachycardia (heart rate >100 beats per minute) is a common finding in severe dehydration as the body attempts to compensate for decreased blood volume by increasing heart rate.

A. Herpes simplex virus (HSV) type 1 B. Hepatitis A C. Human papillomavirus (HPV) D. Pediculosis capitis

Correct Answer is B

Explanation

A. Herpes simplex virus (HSV) type 1 infection is not typically a reportable diagnosis to the CDC unless it is part of a larger outbreak or cluster of cases.

B. Hepatitis A is a reportable infectious disease to the CDC due to its potential for public health significance, particularly in outbreaks or clusters of cases.

C. Human papillomavirus (HPV) infection is not typically a reportable diagnosis to the CDC unless it is part of a larger study or surveillance effort.

D. Pediculosis capitis (head lice infestation) is not typically a reportable diagnosis to the CDC unless it is part of a larger outbreak or cluster of cases.

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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?

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