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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Free Nursing Study Resources

Correct Answer is A

Explanation

A. Brainstorming sessions with nurses can generate new ideas and perspectives to address public health concerns such as rising rates of sexually transmitted infections. It allows for creative

thinking and collaboration among team members.

B. While a community-wide program may be part of the solution, it may not directly involve generating new ideas within the healthcare team.

C. Role-playing with nurses may be beneficial for training and education purposes but may not specifically focus on generating new ideas to address the public health concern.

D. Personal discussions with clients may provide valuable insights into individual experiences and needs but may not be the most effective method for generating new ideas on a broader scale to address community-wide concerns.

A. A client who has heart failure and reports shortness of breath while ambulating B. A client who has abdominal pain and is vomiting coffee-ground emesis C. A client who has benign prostatic hyperplasia and is unable to urinate D. A client who had an open cholecystectomy and has green drainage from the T-tube

Correct Answer is B

Explanation

A. This client's symptom of shortness of breath while ambulating indicates possible worsening heart failure, which requires prompt assessment but is not immediately life-threatening.

B. Vomiting coffee-ground emesis suggests upper gastrointestinal bleeding, which could be

indicative of a serious condition such as a gastrointestinal ulcer or tear and requires immediate assessment to determine the cause and initiate appropriate treatment.

C. While urinary retention in a client with benign prostatic hyperplasia requires attention, it is not as urgent as upper gastrointestinal bleeding.

D. Green drainage from the T-tube in a client who had an open cholecystectomy may indicate bile leakage, which requires assessment and intervention, but upper gastrointestinal bleeding takes precedence due to its potential for rapid deterioration.

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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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Naxlex Comprehensive Predictor Exams

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Correct Answer is A

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Correct Answer is B

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