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.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
When caring for a client with preeclampsia receiving magnesium sulfate, the nurse should instruct the client to report any increased muscle weakness. Magnesium sulfate is a medication commonly used to prevent and treat seizures in clients with preeclampsia. However, one of the side effects of magnesium sulfate is muscle weakness. If the client experiences an increase in muscle weakness, it could indicate magnesium toxicity, which requires immediate medical attention.
Option a) Increased respiratory rate is not typically associated with magnesium sulfate administration. However, respiratory depression is a potential side effect, so a decreased respiratory rate should be reported.
Option b) Increased fetal movement is generally considered a positive sign of fetal well-being and is not a concern that needs to be reported.
Option c) Increased urinary output is not typically a concerning finding. In fact, maintaining adequate urine output is desired in clients with preeclampsia to ensure proper kidney function. However, a sudden decrease in urinary output or signs of dehydration should be reported.
Correct Answer is C
Explanation
Endometritis is an infection of the endometrium, the lining of the uterus, typically occurring after childbirth. When assessing a client with endometritis, the nurse should expect to find uterine tenderness as a common clinical finding. This finding is consistent with endometritis, which is characterized by inflammation and infection of the endometrium. Additional signs and symptoms may include an elevated temperature, increased lochia, foul-smelling lochia, and an elevated WBC count. Prompt identification and treatment of endometritis are important to prevent further complications.
Option a) A temperature of 37.4°C (99.3°F) is within the normal range and does not necessarily indicate endometritis. However, an elevated temperature above 38°C (100.4°F) or a persistent fever may be indicative of an infection and should be further evaluated.
Option b) Scant lochia (minimal vaginal bleeding) is not a characteristic finding of endometritis. In endometritis, lochia is often increased in amount and may have an unpleasant odor.
Option d) A white blood cell (WBC) count of 9,000/mm³ is within the normal range. However, in cases of endometritis, there is usually an elevation in the WBC count as a response to the infection. An elevated or increasing WBC count may be observed.
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