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.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A reason:
Scant scalp hair is not an expected finding for a newborn who is post-term. Scant scalp hair is more common in preterm infants who have not developed fully.
Choice B reason:
Copious vernix is not an expected finding for a newborn who is post-term. Vernix is a white, cheesy substance that covers the skin of the fetus and protects it from the amniotic fluid. Vernix is usually abundant in preterm infants and decreases as gestation progresses.
Choice C reason:
Increased subcutaneous fat is not an expected finding for a newborn who is post-term. Increased subcutaneous fat is a sign of adequate nutrition and growth, which is more likely in term infants. Post-term infants may have reduced subcutaneous fat due to placental insufficiency and decreased nutrient supply.
Choice D reason:
Dry, cracked skin is an expected finding for a newborn who is post-term. Dry, cracked skin is a result of prolonged exposure to the amniotic fluid, which causes dehydration and desquamation of the skin. Post-term infants may also have meconium staining on their skin due to fetal distress.
Correct Answer is ["A","C","D","E"]
Explanation
Choice A reason:
Cerebral palsy is a disorder that affects movement, posture, and muscle tone. It can be caused by brain damage that occurs before, during, or after birth. Premature babies are at a higher risk of developing cerebral palsy because they are more likely to have bleeding in the brain, lack of oxygen to the brain, infections or other complications that can damage the brain.
Choice B reason:
Color blindness is a condition that affects the ability to see colors or differences in colors. It is usually inherited and not related to prematurity. However, some premature babies may develop retinopathy of prematurity, which can affect their vision in other ways.
Choice C reason:
Learning disabilities are problems that affect the ability to learn, read, write, speak or do math. They can be caused by genetic factors, environmental factors or brain injuries.
Premature babies are more likely to have learning disabilities because they are more likely to have brain damage, low birth weight, infections or other complications that can affect their brain development.
Choice D reason:
Retinopathy is a disease that affects the blood vessels in the retina, the light-sensitive layer of tissue at the back of the eye. Retinopathy of prematurity is a condition that occurs when the blood vessels in the retina grow abnormally in premature babies. This can cause bleeding, scarring or detachment of the retina, which can lead to vision loss or blindness.
Choice E reason:
Apnea is a condition that causes pauses in breathing during sleep. Apnea of prematurity is a condition that affects premature babies who have not fully developed their nervous system and respiratory system. This can cause them to stop breathing for more than 20 seconds at a time, which can lower their oxygen levels and heart rate.
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