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:
The newborn has hypotonia. This is not a specific sign of brachial plexus injury, as hypotonia can have many other causes, such as genetic disorders, infections, or brain damage.
Hypotonia is a general term for low muscle tone or weakness, which can affect the whole body or specific parts.
Choice B reason:
The newborn does not demonstrate the Moro reflex. This is a sign of brachial plexus injury, especially if it affects only one arm. The Moro reflex is a startle response that causes the baby to throw out the arms and legs, then curl them in when startled. A brachial plexus injury can impair the nerve function in the shoulder, arm, or hand, leading to decreased movement or sensation in the upper extremity. If the baby does not show the Moro reflex on one side, it may indicate damage to the upper brachial plexus nerves (C5-C7), also known as Erb's palsy.
Choice C reason:
The newborn cries continually. This is not a specific sign of brachial plexus injury, as crying can have many other causes, such as hunger, discomfort, or colic. Crying is a normal way for babies to communicate their needs and feelings. Crying does not necessarily indicate pain from a brachial plexus injury, as infants' nerves behave differently from adults' and they may not experience much pain from this condition.
Choice D reason:
The newborn has tremors. This is not a specific sign of brachial plexus injury, as tremors can have many other causes, such as cold temperature, low blood sugar, or withdrawal from maternal medications. Tremors are involuntary movements of the muscles that can affect the whole body or specific parts. Tremors do not necessarily indicate nerve damage from a brachial plexus injury, as this condition usually causes weakness or paralysis of the affected muscles.
Correct Answer is D
Explanation
Choice A reason:
Fetal heart rate irregularities are not a sign of hydatidiform mole, as this condition involves an abnormal fertilization of the egg that results in an abnormal or absent fetus.
Choice B reason:
A hydatidiform mole is more commonly associated with dark brown to bright red vaginal bleeding, not whitish discharge. The bleeding may resemble prune juice and is often a sign of the abnormality.
Choice C reason:
Rapidly dropping human chorionic gonadotropin (hCG) levels are not a sign of hydatidiform mole, as this condition causes very high levels of hCG due to the proliferation of trophoblastic tissue.
Choice D reason:
In a hydatidiform mole, the uterus often enlarges more rapidly than expected for the gestational age due to the overgrowth of trophoblastic tissue and the accumulation of fluid-filled vesicles. This excessive uterine enlargement is a key sign that could indicate the presence of a molar pregnancy.
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