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?

Apply a thin layer of lotion to the newborn's skin every 4 hr.

Give the newborn 1 oz of glucose water every 4 hr.

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

Choice A rationale:

The nurse should not apply lotion to the newborn's skin during phototherapy. Phototherapy involves exposing the newborn's skin to light to treat jaundice by breaking down bilirubin. Applying lotion may interfere with the effectiveness of the therapy and may not be recommended as it can make it difficult for the skin to release heat generated during the process.

Choice B rationale:

Giving the newborn glucose water every 4 hours is not a necessary action during phototherapy. The primary concern during phototherapy is to treat jaundice, and giving glucose water may not have a direct impact on the effectiveness of the treatment. Additionally, it is important to focus on monitoring the newborn's bilirubin levels and hydration status.

Choice D rationale:

Dressing the newborn in a thin layer of clothing during phototherapy is not recommended. Phototherapy works best when the newborn's skin is exposed to a light source, and covering the skin with clothing may decrease the effectiveness of the treatment.

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Correct Answer is C

Explanation

The correct answer is **Choice C: A client who has salicylate intoxication.**

Choice A rationale:

A client taking a thiazide diuretic is at risk for metabolic alkalosis, not metabolic acidosis. Thiazide diuretics can cause a loss of potassium and chloride, leading to a relative increase in bicarbonate and a higher pH, resulting in metabolic alkalosis.

Choice B rationale:

A client who is vomiting is at risk for metabolic alkalosis, not metabolic acidosis. Vomiting leads to a loss of gastric acid (hydrochloric acid), resulting in a relative increase in bicarbonate and a higher pH, leading to metabolic alkalosis.

Choice C rationale:

A client with salicylate intoxication is at risk for metabolic acidosis. Salicylates, the active ingredient in aspirin, can cause an increased production of organic acids, leading to a decrease in pH and the development of metabolic acidosis.

Choice D rationale:

A client with hypoventilation is at risk for respiratory acidosis, not metabolic acidosis. Hypoventilation leads to a buildup of carbon dioxide, which dissolves in the blood to form carbonic acid, resulting in a decrease in pH and respiratory acidosis.

A. "I will need to obtain a sample of the discharge for laboratory testing.". B. "Apply povidone-iodine solution twice daily to the circumcision site.". C. "Wipe the discharge away gently with a washcloth and warm water for the next 48 hours.". D. "The discharge is common during the first 24 to 72 hours following a circumcision.".

Correct Answer is D

Explanation

Choice A rationale:

The nurse does not need to obtain a sample of the discharge for laboratory testing at this point. Yellow discharge after circumcision is common and generally not a cause for immediate concern. Laboratory testing is not necessary for routine circumcision care.

Choice B rationale:

Applying povidone-iodine solution twice daily to the circumcision site is not recommended in this situation. Povidone-iodine may cause irritation and delay the natural healing process.

Generally, no specific cleaning solution is required for circumcision care unless otherwise indicated by a healthcare provider.

Choice C rationale:

Wiping the discharge away gently with a washcloth and warm water for the next 48 hours is not the most appropriate action. The circumcision site should be kept clean and dry, but actively wiping away the discharge may cause irritation and disrupt the natural healing process.

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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?

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Naxlex Comprehensive Predictor Exams

A nurse is reviewing the medical records of four clients who have an acid-base imbalance. The nurse should recognize that which of the following clients is at risk for metabolic acidosis?

Correct Answer is C

Explanation

A nurse is providing teaching to a client who reports that her baby has yellow discharge forming at the circumcision site. Which of the following is an appropriate response by the nurse?

Correct Answer is D

Explanation

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