An 18-hour-old infant with hyperbilirubinemia is placed under phototherapy bank lights. Which of the following is an appropriate intervention for this infant?
Keep eye shields on at all times, including when feeding
Routinely monitor temperature while infant is in the crib
Tightly swaddle the infant in blanket
Expose as much of the infant's skin to the lights as possible
The Correct Answer is D
A. Keep eye shields on at all times, including when feeding. Incorrect because while eye protection is crucial under the lights, they can be removed during feedings to allow for parent-infant bonding and eye contact.
B. Routinely monitor temperature while the infant is in the crib. Incorrect, because temperature should be closely monitored while the infant is under phototherapy due to potential changes in body temperature caused by the exposure.
C. Tightly swaddle the infant in a blanket. Incorrect, as this would reduce the amount of skin exposed to the phototherapy lights and decrease the treatment's effectiveness.
D. Expose as much of the infant's skin to the lights as possible. Phototherapy is most effective when as much skin as possible is exposed to the lights because it allows for maximum light absorption and more effective bilirubin breakdown.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. The newborn who has cyanotic hands and feetCyanosis, a bluish or purplish discoloration of the skin, in the hands and feet of a newborn can indicate a breathing problem or poor circulation. This requires prompt evaluation by a healthcare provider.
B. The newborn whose head turns toward the cheek being stroked. This describes the rooting reflex, which is normal.
C. The newborn whose toes curl when the lateral heel is stroked. This describes the Babinski reflex, which is also normal for infants.
D. The newborn who extends the arms when hearing a loud noise. This describes the Moro reflex, which is normal and should not require reporting.
Correct Answer is A
Explanation
A. Pain. Pain is the hallmark symptom of a sickle cell crisis due to the vaso-occlusion of sickled red blood cells blocking blood flow and causing ischemia in various tissues and organs.
B. High fever. While fever can occur if there is an associated infection, it is not a primary feature of sickle cell crisis.
C. Bradycardia. Sickle cell crisis can cause tachycardia due to pain and stress, but not bradycardia.
D. Constipation. This is not a typical symptom associated with a sickle cell crisis.
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