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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. Providing guidance on incentive spirometry requires specialized knowledge and skill that should be provided by a licensed healthcare provider, such as a nurse.
B. A client who had a myocardial infarction 3 days ago and reports chest discomfort requires ongoing assessment and monitoring by a licensed healthcare provider, such as a nurse, due to the potential for cardiac complications.
C. Assisting a client who had a stroke 2 days ago and needs help toileting is a task that can be safely delegated to an assistive personnel, as long as the client's condition is stable and the assistive personnel has been trained in providing basic care.
D. Providing a drink to a client who has awoken following a bronchoscopy may require assessment and monitoring for potential complications, such as aspiration or respiratory distress, which should be provided by a licensed healthcare provider, such as a nurse.
Correct Answer is C
Explanation
A. While hydrogen peroxide has some disinfectant properties, it is not as effective as other agents like chlorine bleach for cleaning surfaces contaminated with blood.
B. Isopropyl alcohol is effective against many pathogens but may not be as effective as chlorine bleach specifically for bloodborne pathogens.
C. Chlorine bleach is an effective agent for cleaning surfaces contaminated with blood and other bodily fluids, as it has strong disinfectant properties.
D. Chlorhexidine is primarily used as an antiseptic for skin preparation and may not be as effective for surface cleaning of blood contamination.
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