A nurse is planning care for a newborn who is scheduled to start phototherapy using a lamp. Which of the following actions should the nurse include in the plan?
Give the newborn 1 oz of glucose water every 4 hours.
Apply a thin layer of lotion to the newborn's skin every 8 hours.
Ensure the newborn's eyes are closed beneath the shield.
Dress the newborn in a thin layer of clothing during therapy.
The Correct Answer is C
Phototherapy is a treatment method used to reduce high levels of bilirubin in the blood of a newborn with jaundice. During phototherapy, the newborn is exposed to special lights that help break down the bilirubin and allow it to be eliminated from the body. It is important to protect the newborn's eyes during phototherapy.
Option a) Giving the newborn 1 oz of glucose water every 4 hours is not necessary for phototherapy. The primary goal of phototherapy is to treat jaundice, and providing glucose water is not directly related to this treatment.
Option b)Applying a thin layer of lotion to the newborn's skin every 8 hours is not necessary during phototherapy. In fact, it is generally recommended to avoid applying lotions or oils to the skin during phototherapy as they can interfere with the effectiveness of the treatment.
Option c) Ensuring the newborn's eyes are closed beneath the shield is essential during phototherapy. The eyes are particularly sensitive to the light used in phototherapy, and exposure to the light can potentially damage the eyes. Therefore, the newborn's eyes should be protected with a shield or eye patches to prevent direct exposure to the light.
Option d) Dressing the newborn in a thin layer of clothing during therapy is appropriate. The newborn should be dressed in a way that allows as much of their skin as possible to be exposed to the phototherapy lights. This usually involves removing unnecessary clothing and covering the genital area with a diaper, while the rest of the body is exposed to the light.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Late decelerations are a type of fetal heart rate (FHR) pattern that indicate fetal hypoxia (lack of oxygen) due to uteroplacental insufficiency (decreased blood flow to the placenta). They are defined as a gradual decrease in FHR that occurs after the peak of a uterine contraction and returns to baseline after the end of the contraction¹. Late decelerations are associated with adverse neonatal outcomes, such as low Apgar scores, acidosis, and neonatal intensive care unit admission².
The nurse should take immediate actions to improve fetal oxygenation and blood flow when late decelerations are detected. The first and most important action is to place the client in a lateral position, either left or right, to reduce compression of the inferior vena cava and increase uterine perfusion. This can improve fetal oxygenation and reduce the severity of late decelerations¹³.
The other actions that the nurse should take are:
- Discontinue oxytocin infusion if it is being used for induction or augmentation of labor, as it can cause uterine tachysystole (excessive contractions) and worsen uteroplacental insufficiency¹³.
- Administer oxygen to the client at 8 to 10 L/min via a nonrebreather face mask to increase maternal oxygen saturation and fetal oxygen delivery¹³.
- Increase intravenous (IV) fluid infusion rate to maintain maternal hydration and blood pressure, which can improve uterine blood flow¹³.
- Notify the provider and prepare for possible operative delivery if late decelerations persist or fetal distress occurs¹³.
- Provide emotional support and reassurance to the client and family, as late decelerations can cause anxiety and fear⁴.
The other options are not actions that the nurse should take:
- a) Administer misoprostol 25 mcg vaginally. This is not correct because misoprostol is a medication that is used to induce labor by ripening the cervix and stimulating contractions. It is not indicated for late decelerations and can cause uterine hyperstimulation and fetal distress⁵.
- c) Administer oxygen via a face mask at 2 L/min. This is not correct because this is too low of an oxygen flow rate to improve fetal oxygenation. The recommended oxygen flow rate for late decelerations is 8 to 10 L/min via a nonrebreather face mask¹³.
- d) Decrease the maintenance IV solution infusion rate. This is not correct because this can cause maternal dehydration and hypotension, which can reduce uterine blood flow and worsen fetal hypoxia. The nurse should increase the IV fluid infusion rate to maintain maternal hydration and blood pressure¹³.
Correct Answer is C
Explanation
Cytomegalovirus (CMV) is a common virus that belongs to the herpes family. Most people who get infected with CMV have no symptoms or only mild symptoms, such as fever, fatigue, or sore throat. However, CMV can cause serious problems in newborns who are infected before birth or around the time of birth. This is called congenital CMV infection¹.
Congenital CMV infection can affect various organs and systems in the newborn, such as the brain, eyes, liver, spleen, lungs, and blood. Some of the possible signs and symptoms of congenital CMV infection are:
- Low birth weight
- Small head size (microcephaly)
- Enlarged liver and spleen (hepatosplenomegaly)
- Yellow skin and eyes (jaundice)
- Purple skin patches or bleeding spots (petechiae or purpura)
- Pneumonia
- Seizures
- Inflammation of the brain (encephalitis) or eye (retinitis)
One of the most common and serious complications of congenital CMV infection is hearing loss. Hearing loss can affect one or both ears and can range from mild to profound. Hearing loss can be present at birth or develop later in childhood. Hearing loss can affect the child's speech, language, and cognitive development².
Hearing loss due to congenital CMV infection is often progressive, meaning that it can worsen over time. Therefore, newborns who are diagnosed with congenital CMV infection should have regular hearing tests to monitor their hearing status and receive early intervention if needed. Early intervention may include hearing aids, cochlear implants, speech therapy, or sign language².
The other options are not typical signs of congenital CMV infection and have different causes:
a) Macrosomia is a condition in which a newborn has a birth weight above the 90th percentile for their gestational age. It can be caused by maternal diabetes, obesity, genetics, or prolonged pregnancy.
b) Cataracts are cloudy areas in the lens of the eye that impair vision. They can be caused by genetic disorders, infections, trauma, or exposure to certain drugs or radiation.
d) Urinary tract infection is an infection of the bladder, urethra, kidneys, or ureters. It can be caused by
bacteria, viruses, fungi, or parasites.
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