A nurse is providing teaching to the parents of a newborn who has a prescription for a home phototherapy biliblanket.
Which of the following statements should the nurse include in the teaching?
You will check your baby's bilirubin level every 6 hours.
You should offer your baby glucose water 1 hour after each feeding.
Your baby's eyes should be covered while on the biliblanket.
You can remove your baby from the biliblanket for feedings.
The Correct Answer is D
Choice A rationale
Bilirubin levels are typically monitored by a healthcare professional and not by parents at home every 6 hours. The frequency of bilirubin checks for a newborn receiving home phototherapy is usually determined by the healthcare provider based on the infant's bilirubin trajectory and clinical status, often daily or as prescribed.
Choice B rationale
Offering glucose water to newborns is not recommended. Glucose water does not provide adequate nutrition and can interfere with successful breastfeeding or formula feeding by reducing the infant's appetite for nutrient-rich milk. Adequate hydration and nutrition are crucial for bilirubin excretion in jaundiced infants.
Choice C rationale
For biliblanket phototherapy, eye coverings are generally not necessary. The biliblanket emits light from a fiber optic pad that is wrapped around the infant's body, and the light does not directly shine into the baby's eyes, unlike traditional overhead phototherapy lights that require eye protection.
Choice D rationale
Removing the baby from the biliblanket for feedings is appropriate and encouraged. Intermittent breaks for feeding and bonding are permissible as long as the total duration of phototherapy prescribed by the healthcare provider is met. Frequent feedings promote bilirubin excretion through stools.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale
A temperature of 37.7° C (99.9° F) in the immediate postpartum period is a relatively common and often benign finding, typically within normal limits or indicating mild dehydration or exertion from labor. A slight elevation is not usually a cause for immediate concern unless accompanied by other signs of infection, which would warrant further investigation. Normal range is 36.5° C to 37.5° C (97.7° F to 99.5° F).
Choice B rationale
A boggy fundus is a significant finding that the nurse should report immediately. A boggy, soft uterus indicates uterine atony, which means the uterine muscles are not contracting effectively. This significantly increases the risk of postpartum hemorrhage due to inadequate compression of uterine blood vessels.
Choice C rationale
Lochia rubra with small clots is considered a normal finding in the immediate postpartum period. Lochia rubra is the initial dark red discharge consisting of blood, decidual tissue, and mucus. Small clots are expected as blood clots and detaches from the uterine wall, reflecting normal uterine involution.
Choice D rationale
Minimal perineal edema is a normal and expected finding after vaginal delivery. The trauma of childbirth often results in some degree of swelling in the perineal area. "Minimal" edema indicates that the swelling is not excessive and does not suggest a complication requiring immediate reporting to the provider.
Correct Answer is A
Explanation
Choice A rationale
Sternal retractions indicate increased respiratory effort and can be a sign of respiratory distress in a newborn. This occurs when the infant is struggling to inhale, causing the chest wall to visibly pull inward with each breath due to negative pressure, and requires immediate intervention.
Choice B rationale
Acrocyanosis, characterized by bluish discoloration of the hands and feet, is a common and normal finding in newborns during the first 24 to 48 hours after birth. It is due to immature peripheral circulation and does not typically indicate a need for intervention.
Choice C rationale
Molding is the overlapping of the fetal skull bones during passage through the birth canal. This is a normal adaptation during vaginal birth and typically resolves spontaneously within a few days, thus requiring no intervention.
Choice D rationale
Vernix caseosa is a whitish, cheesy substance covering the skin of many newborns, providing protection and lubrication in utero. Its presence is normal and beneficial, often providing hydration and antimicrobial properties to the skin post-birth.
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