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 D
Explanation
The correct answer is choice D: Place the client in a lateral position. Late decelerations of the fetal heart rate on the monitor tracing can indicate fetal distress, which is a potential complication of oxytocin induction of labor. Placing the client in a lateral position can improve uteroplacental blood flow and may improve fetal oxygenation.
Choice A, administering misoprostol 25 mcg vaginally, can increase uterine contractions and may further compromise fetal oxygenation. Choice B, decreasing maintenance IV solution infusion rate, and choice C, administering oxygen via face mask at 2 L/min, are not effective interventions for late decelerations of the fetal heart rate.
Correct Answer is D
Explanation
A.Cranial bone overlap (molding) is common after vaginal delivery due to compression during birth. It typically resolves within a few days and does not require urgent intervention.
B.These are called milia, which are harmless and expected in newborns. They resolve spontaneously without treatment.
C.This is known as acrocyanosis, a normal finding in newborns during the first 24–48 hours of life due to immature circulation. It is not a cause for concern unless central cyanosis is present (e.g., lips or mucous membranes are blue).
D.Abnormal positioning of the ears (e.g., low-set or forward and lateral) can be a sign of congenital anomalies, particularly renal abnormalities or chromosomal syndromes such as Trisomy 21 (Down syndrome) or Trisomy 18. Because these may indicate serious underlying systemic conditions, the nurse must report this finding promptly to initiate further evaluation and possibly diagnostic testing (e.g., renal ultrasound or genetic consultation).
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