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 B

Explanation

A. While explaining the consequences of refusal is important, it may not address the underlying reason for the refusal and should come after identifying the reason.

B. Identifying the reason for the client's refusal is the first step in addressing the issue and may help determine the appropriate intervention.

C. Documenting the client's refusal is important but should not be the first action taken without understanding the reason for the refusal.

D. Informing the provider of the client's refusal may be necessary, but it should come after identifying the reason for the refusal and attempting to address it.

A. "Your PICC line will allow long-term access for antibiotic therapy." B. "You should use a 5-milliliter barrel syringe to flush your PICC line at home." C. "Your PICC line must be placed in your nondominant arm." D. "You should immobilize the arm with the PICC line using a sling."

Correct Answer is A

Explanation

A. "Your PICC line will allow long-term access for antibiotic therapy." - PICC lines are often used for long-term administration of medications, including antibiotics, due to their durability and ease of use.

B. "You should use a 5-milliliter barrel syringe to flush your PICC line at home." - The size of the syringe used to flush a PICC line depends on the facility's protocol and the client's specific

needs. Specific instructions regarding syringe size should be provided by the healthcare provider or nurse.

C. "Your PICC line must be placed in your nondominant arm." - The choice of arm for PICC line placement depends on various factors, including vein integrity and the client's comfort. There is no strict requirement for the PICC line to be placed in the nondominant arm.

D. "You should immobilize the arm with the PICC line using a sling." - Immobilizing the arm with a sling is not typically necessary after PICC line placement. Clients are usually instructed to avoid excessive movement and to keep the arm clean and dry to prevent complications.

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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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