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 B
Explanation
Choice A reason:
Swimming is one of the best and safest exercises for pregnant women. It exercises your large muscle groups, provides cardiovascular benefits, reduces swelling, and allows you to feel weightless. Swimming is also a low-impact exercise that does not put too much stress on your joints and muscles. Therefore, this statement does not indicate a need for additional teaching.
Choice B reason:
Racquetball is not an appropriate exercise during pregnancy. It is a high-impact sport that involves sudden changes of direction, quick movements, and the risk of falling or getting hit by the ball or the racquet. These factors can increase the chance of injury, bleeding, or premature labor. Therefore, this statement indicates a need for additional teaching.
Choice C reason:
Cycling on a stationary bike is a safe exercise during pregnancy. It provides moderate aerobic conditioning and relieves stress and tension in your joints and muscles. Cycling on a stationary bike also reduces the risk of falling or losing balance compared to cycling on a regular bike. Therefore, this statement does not indicate a need for additional teaching.
Choice D reason:
Yoga is a beneficial exercise during pregnancy. It can help you relax, improve your flexibility, strengthen your muscles, and prepare your body for labor and delivery. Yoga can also help you cope with symptoms of depression and anxiety during pregnancy. However, you should avoid hot yoga or poses that involve lying flat on your back, twisting your abdomen, or compressing your belly. Therefore, this statement does not indicate a need for additional teaching.
Correct Answer is A
Explanation
Choice A reason:
Hypoglycemia is a common complication for newborns whose mothers have diabetes mellitus. This is because the newborn's pancreas produces excessive insulin in response to the high glucose levels in the mother's blood during pregnancy. After birth, the newborn's glucose levels drop rapidly, while the insulin levels remain high, resulting in hypoglycemia. The nurse should monitor the newborn's blood glucose levels and signs of hypoglycemia, such as jitteriness, lethargy, poor feeding, and temperature instability.
Choice B reason:
Decreased RBC is not a likely complication for newborns whose mothers have diabetes mellitus. In fact, these newborns may have increased RBC due to chronic fetal hypoxia caused by placental insufficiency. The nurse should monitor the newborn's hematocrit and signs of polycythemia, such as ruddy skin, jaundice, and respiratory distress.
Choice C reason:
Hyperbilirubinemia is not a likely complication for newborns whose mothers have diabetes mellitus. In fact, these newborns may have increased bilirubin levels due to hemolysis of excess RBC and delayed hepatic clearance. The nurse should monitor the newborn's serum bilirubin levels and signs of jaundice, such as yellow skin and sclera, poor feeding, and lethargy.
Choice D reason:
Hypercalcemia is not a likely complication for newborns whose mothers have diabetes mellitus. In fact, these newborns may have hypocalcemia due to decreased parathyroid hormone secretion and increased calcium binding to albumin. The nurse should monitor the newborn's serum calcium levels and signs of hypocalcemia, such as jitteriness, tremors, seizures, and cardiac arrhythmias.
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