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 hr.
Apply a thin layer of lotion to the newborn's skin every 8 hr.
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
The correct answer is choice C, Ensure the newborn's eyes are closed beneath the shield. Phototherapy is a treatment used to reduce high bilirubin levels in newborns. It involves exposing the newborn's skin to special lights, which helps to break down the excess bilirubin in the blood. It is important to ensure that the newborn's eyes are closed beneath the shield to prevent damage to the eyes from the bright lights. Giving the newborn 1 oz of glucose water every 4 hr, applying lotion to the newborn's skin every 8 hr, and dressing the newborn in a thin layer of clothing during therapy are not indicated interventions during phototherapy.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Three uterine contractions within a 20-min period require intervention by the nurse during a nonstress test at 35 weeks of gestation. The nonstress test is used to assess fetal well-being by monitoring the fetal heart rate (FHR) response to fetal movement. The test is considered reactive if there are two or more accelerations of the FHR within a 20-min period, each lasting at least 15 seconds and peaking at least 15 beats above the baseline. In this scenario, the finding that requires intervention by the nurse is three uterine contractions within a 20-min period. This is because frequent or prolonged contractions can indicate preterm labor, which requires immediate intervention
to prevent premature delivery. The nurse should assess the client for signs and symptoms of preterm labor, such as pelvic pressure, low back pain, vaginal bleeding or discharge, and abdominal cramping. The nurse should also notify the provider and prepare the client for further evaluation and possible interventions, such as tocolytic therapy to stop the contractions.
Correct Answer is A
Explanation
The nurse should inform the client that it is common for yellow discharge to form at the circumcision site during the first 24 to 72 hours following the procedure. This is due to the accumulation of exudate, which is a normal part of the healing process. The nurse does not need to obtain a sample of the discharge for laboratory testing. The povidone-iodine solution should not be applied to the circumcision site, as it can be caustic and delay healing. Wiping the discharge away gently with a washcloth and warm water may irritate the wound and cause additional trauma.
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