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 C
Explanation
A. A 10-year-old with a burn on the palm of the hand: This could potentially be accidental, for example, from touching a hot surface. However, while it requires further investigation, it is not as strongly indicative of abuse as the given option.
B. A 6-year-old with splash burns on the front torso: These burns could result from accidentally spilling hot liquids. Though it raises concern, it often indicates an accident rather than abuse unless accompanied by other suspicious signs.
C. A 4-year-old with circular abrasions around the wrists: This is highly suspicious of abuse because circular abrasions can indicate that the child may have been tied or restrained, which is not typical of accidents or normal play.
D. A 2-year-old with a large bruise on the forehead: This type of injury is common in young children who are prone to falls and bumps. It might not immediately suggest abuse without additional context.
Correct Answer is D
Explanation
A. Administer Oxytocin IV per MD orders. This may be done after attempting fundal massage to help firm the uterus, but massage is the first step.
B. Notify the healthcare provider. This would be done if the fundus does not respond to massage or if excessive bleeding continues, but not before attempting to firm the fundus.
C. Document the fundal height and consistency. Documentation is important but should occur after addressing the immediate issue of a soft fundus to prevent hemorrhage.
D. Massage the fundus until it firms. The immediate action should be to massage the uterus to promote contraction and reduce bleeding. A soft, spongy uterus indicates uterine atony, which can lead to hemorrhage.
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