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.

Answer and Explanation

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.

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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.

A. A client who is at 12 weeks of gestation and is experiencing nausea and vomiting B. A client who is at 34 weeks of gestation and is experiencing epigastric pain and headache C. A client who is at 38 weeks of gestation and is experiencing painful urination D. A client who is at 39 weeks of gestation and is experiencing cramping and spotting

Correct Answer is B

Explanation

Among the given options, the client who is at 34 weeks of gestation and experiencing epigastric pain and headache should be assessed first. Epigastric pain and headache can be signs of preeclampsia, a serious condition characterized by high blood pressure and organ dysfunction during pregnancy. Preeclampsia requires immediate attention as it can lead to complications for both the mother and the fetus.

Option a) A client at 12 weeks of gestation experiencing nausea and vomiting may be experiencing normal symptoms of early pregnancy. While it is important to assess the client's well-being, it is not an immediate priority compared to the potential signs of preeclampsia in option b.

Option c) A client at 38 weeks of gestation experiencing painful urination may indicate a urinary tract infection (UTI). While a UTI should be addressed, it does not pose the same level of immediate risk as the potential signs of preeclampsia in option b.

Option d) A client at 39 weeks of gestation experiencing cramping and spotting may be in early labor or have other signs of impending labor. While it is important to assess this client's condition, it is not an immediate priority compared to the potential signs of preeclampsia in option b.

Therefore, the nurse should assess the client who is at 34 weeks of gestation and experiencing epigastric pain and headache as the first priority. Prompt evaluation and management of preeclampsia symptoms are crucial to prevent complications and ensure the well-being of both the mother and the fetus.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is C

Explanation

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Correct Answer is B

Explanation

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