A nurse is updating the plan of care for a newborn who is undergoing phototherapy. Which of the following actions should the nurse include in the plan?
Monitor the newborn's blood glucose level hourly.
Apply lotion to the newborn's skin twice per day.
Maintain the newborn in a prone position
Encourage the newborn to breastfeed every 2 hr.
The Correct Answer is D
Choice A reason:
Monitoring the newborn's blood glucose level hourly is not necessary for a newborn undergoing phototherapy. Phototherapy does not affect blood glucose levels, and hourly monitoring would be too invasive and stressful for the newborn. •
Choice B reason:
Applying lotion to the newborn's skin twice per day is not recommended for a newborn undergoing phototherapy. Lotion can interfere with the effectiveness of the phototherapy and increase the risk of skin irritation or infection. •
Choice C reason:
Maintaining the newborn in a prone position is not advisable for a newborn undergoing phototherapy. The newborn should be positioned on alternate sides to expose as much skin surface as possible to the light source. •
Choice D reason:
Encouraging the newborn to breastfeed every 2 hr is an appropriate action for a newborn undergoing phototherapy. Frequent feeding helps to promote hydration and the elimination of bilirubin from the body.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A reason:
Nevus flammeus is a port-wine stain, a type of birthmark that is present at birth and does not fade over time. It is caused by a malformation of capillaries in the skin and appears as a reddish-purple patch. It can occur anywhere on the body but is not associated with swelling or suture lines.
Choice B reason:
Cephalhematoma is a collection of blood under the periosteum of the skull bone, usually caused by trauma during delivery. It appears as a swollen area on the head that does not cross the suture line because it is limited by the boundaries of the bone. It usually resolves within a few weeks or months without treatment.
Choice C reason:
Molding is the temporary change in the shape of the newborn's head due to the pressure of the birth canal during delivery. It results in an elongated or cone-shaped head that may cross the suture line. It usually resolves within a few days as the skull bones return to their normal position.
Choice D reason:
Caput succedaneum is a localized swelling of the scalp, usually caused by pressure from the cervix or vacuum extraction during delivery. It appears as a soft, puffy area on the head that crosses the suture line because it is not limited by the bone. It usually resolves within a few days without treatment.
Correct Answer is C
Explanation
Choice A reason:
Heat facilitates the drainage of mucus for a premature newborn. This is incorrect because heat does not affect mucus drainage. Mucus drainage is more related to suctioning and hydration.
Choice B reason:
The newborn has a small body surface for his weight. This is incorrect because a small body surface area for weight would indicate a large newborn, not a premature one. A large newborn would have less risk of heat loss than a small one.
Choice C reason:
The newborn's temperature control mechanism is immature. This is correct because premature newborns have immature thermoregulation and are prone to hypothermia. Placing the newborn in an incubator helps maintain a stable temperature and prevent further complications.
Choice D reason:
Heat increases the flow of oxygen to the newborn's extremities. This is incorrect because heat does not directly affect oxygen delivery. Oxygen delivery is more related to ventilation, perfusion, and hemoglobin levels. The question is about a premature newborn who has signs of respiratory distress, such as nasal flaring, intercostal retractions, expiratory grunting, and mild cyanosis. These signs indicate that the newborn is having difficulty breathing and may have a condition such as respiratory distress syndrome, transient tachypnea of the newborn, or meconium aspiration syndrome. The nurse should place the newborn in an incubator to provide warmth and prevent heat loss, which can worsen respiratory distress. The nurse should also monitor the newborn's vital signs, oxygen saturation, blood gases, chest x-ray, and neonatal abstinence scoring system if indicated. The nurse should be prepared to administer oxygen, surfactant, or mechanical ventilation as ordered.
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