A nurse is preparing to administer phototherapy to a newborn with macrosomia who has hyperbilirubinemia.
Which of the following interventions should the nurse include in the plan of care?
Cover the newborn’s eyes with eye shields or patches.
Apply sunscreen lotion to the newborn’s skin before exposure.
Feed the newborn every 4 hours to prevent dehydration.
Turn off the phototherapy lights during blood draws.
The Correct Answer is A
Cover the newborn’s eyes with eye shields or patches. This is because phototherapy exposes the newborn to high-intensity light that can damage the retina and cause eye irritation. Eye shields or patches should be removed every 4 hours to check for eye infection, injury, or displacement.
Choice B is wrong because sunscreen lotion can block the effect of phototherapy and increase the risk of skin irritation and infection. The newborn’s skin should be exposed as much as possible to the light source.
Choice C is wrong because feeding the newborn every 4 hours is not enough to prevent dehydration. Phototherapy can increase insensible water loss and fluid requirements. The newborn should be fed every 2 to 3 hours or on demand, and the urine output and weight should be monitored closely.
Choice D is wrong because turning off the phototherapy lights during blood draws can reduce the efficacy of the treatment and prolong the duration of exposure. The lights should be turned off only when absolutely necessary, such as during physical examination or parental bonding.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
“I should expect to have a cesarean section because vaginal delivery is too risky.” This statement indicates a need for further teaching because it is not true that all women with diabetes mellitus and macrosomia need to have a cesarean section.
The mode of delivery depends on several factors, such as the estimated fetal weight, the maternal pelvic size, the fetal position, and the presence of any complications.
The nurse should explain to the client that vaginal delivery may be possible if the conditions are favorable and the risks are low.
Choice A is wrong because it is a correct statement.
Women with diabetes mellitus should monitor their blood glucose levels closely and follow their prescribed diet to prevent hyperglycemia and fetal macrosomia.
Choice B is wrong because it is also a correct statement.
Women with diabetes mellitus and macrosomia should have regular prenatal visits and ultrasounds to monitor their baby’s growth and well-being.
Choice D is wrong because it is another correct statement.
Women with diabetes mellitus and macrosomia should be aware of the signs of hypoglycemia in their baby after birth, such as jitteriness, lethargy, poor feeding, and low temperature.
The baby may need glucose supplementation or intravenous fluids to maintain normal blood glucose levels.
Normal ranges:
• Blood glucose levels: 70-110 mg/dL (3.9-6.1 mmol/L) for fasting; <140 mg/dL (<7.8 mmol/L) for postprandial
• Estimated fetal weight: 2500-4000 g (5.5-8.8 lb) for term
Correct Answer is B
Explanation
Observe the range of motion of the shoulders and arms.This is because a brachial plexus injury affects the nerve network that provides feeling and muscle control in the shoulder, arm, forearm, hand, and fingers.A baby with a brachial plexus injury may have full or partial lack of movement, a weakened grip, numbness, or an odd position of the affected arm.
Observing the range of motion of the shoulders and arms can help detect any signs of nerve damage or weakness.
Choice A is wrong because palpating the clavicles for crepitus or deformity is a way to check for a possible clavicular fracture, not a brachial plexus injury.
Choice C is wrong because measuring the head circumference and comparing it with the chest circumference is a way to check for a possible cephalopelvic disproportion (CPD), not a brachial plexus injury.
Choice D is wrong because auscultating the lungs for crackles or wheezes is a way to check for a possible respiratory distress, not a brachial plexus injury.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.