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. Encourage the client to ambulate in the hallway 1 hr before bedtime - While light exercise during the day can promote better sleep, exercising close to bedtime can actually disrupt sleep.

B. Tell the client to avoid drinking fluids 1 hr before bedtime - While limiting fluids close to bedtime can reduce nighttime awakenings to urinate, it may not directly address difficulty falling asleep.

C. Schedule routine care tasks during hours when the client is awake - This action ensures that the client can maximize restful sleep during the night by minimizing disruptions from care

activities.

D. Advise the client to leave the television in the room on when trying to fall asleep - Screen

time before bed can interfere with falling asleep due to the stimulating effect of light and content.

A. Troponin 11.8 ng/mL B. Erythrocyte sedimentation rate (ESR) 17 mm/hr C. Human B-type natriuretic peptide 88 pg/ml. D. aPTT 80 seconds

Correct Answer is A

Explanation

A. Troponin is a protein released into the bloodstream when there is damage to the heart muscle (myocardium), such as during a heart attack. Elevated troponin levels indicate myocardial injury or damage, making this the correct choice for indicating myocardial damage.

B. Erythrocyte sedimentation rate (ESR) measures the rate at which red blood cells settle in a tube of blood. It is a non-specific marker of inflammation and is not specific to myocardial damage.

C. Human B-type natriuretic peptide (BNP) is released by the heart in response to increased pressure and volume. Elevated levels are indicative of heart failure, not necessarily myocardial damage.

D. Activated partial thromboplastin time (aPTT) measures the time it takes for blood to clot. It is used to monitor the effectiveness of anticoagulant therapy and is not specific to myocardial

damage.

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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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