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: Verify that informed consent is obtained prior to administration. Choice A rationale: Placing the client in a semi-Fowler’s position is not specifically related to the administration of dinoprostone. This position is often used post-administration to promote comfort and labor progression, but it is not a required action prior to the administration of dinoprostone. Choice B rationale: Instructing the client to avoid urinary elimination until after administration is not necessary. There is no evidence to suggest that retaining urine affects the efficacy or safety of dinoprostone administration. Choice C rationale: Verifying that informed consent is obtained prior to administration is crucial. Dinoprostone, like any medication used to induce labor, carries potential risks and side effects. It is essential that the client is informed about these risks and consents to the procedure before the medication is administered. Choice D rationale: Allowing the medication to reach room temperature prior to administration is not a standard requirement for dinoprostone inserts. Medications have specific storage and administration guidelines that should be followed according to the manufacturer’s instructions and facility protocols.

A. "The nurse should determine the Apgar score at 2 and 7 minutes after birth.”. B. "The nurse should identify that the newborn is in severe distress with an Apgar score of 8.”. C. "The nurse should wait for the first Apgar score before initiating resuscitation efforts.”. D. "The nurse should measure the newborn's muscle tone when assigning an Apgar score.".

Correct Answer is D

Explanation

The correct answer is choice d. “The nurse should measure the newborn’s muscle tone when assigning an Apgar score.”

Choice A rationale:

The Apgar score is determined at 1 and 5 minutes after birth, not at 2 and 7 minutes.

Choice B rationale:

An Apgar score of 8 indicates that the newborn is in good health, not severe distress. Scores of 7-10 are considered normal.

Choice C rationale:

Resuscitation efforts should not be delayed until the first Apgar score is obtained. Immediate resuscitation is initiated if needed, regardless of the Apgar score.

Choice D rationale:

Muscle tone is one of the five criteria assessed in the Apgar score, along with appearance, pulse, grimace, and respiration.

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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

A nurse is assisting the provider to administer a dinoprostone insert to induce labor for a client. Which of the following actions should the nurse take?

Correct Answer is C

Explanation

A nurse is teaching a newly hired nurse about Apgar scoring. Which of the following statements by the newly hired nurse indicates an understanding of the teaching?

Correct Answer is D

Explanation

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A nurse is assessing a newborn who is 4 hr old. Which of the following findings should the nurse identify as the priority to report to the provider?

A nurse is caring for a client who is in active labor. The nurse administers butorphanol IV bolus for pain. Which of the following findings should the nurse report to the provider following this medication?

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