Exhibits
The nurse is assisting in the initiation of phototherapy. For each nursing action, specify if the action is indicated or not indicated for the newborn.
Cover the newborn’s eyes with an eye shield.
Reposition the newborn every 2 to 3 hr.
Apply lotion to the newborn’s skin regularly.
Ensure the newborn wears a hat during phototherapy.
Move the lights closer to the newborn to increase body temperature.
The Correct Answer is {"A":{"answers":"A"},"B":{"answers":"A"},"C":{"answers":"A"},"D":{"answers":"B"},"E":{"answers":"B"}}
- Cover the newborn's eyes with an eye shield ✅ This is essential to prevent retinal damage from the phototherapy light.
- Reposition the newborn every 2 to 3 hr ✅ Repositioning ensures even exposure to light and prevents pressure injuries.
- Apply lotion to the newborn's skin regularly ❌ Lotion is contraindicated as it may interfere with light absorption and increase the risk of burns.
- Ensure the newborn wears a hat during phototherapy ❌ A hat reduces the surface area exposed to light, decreasing phototherapy effectiveness.
- Move the lights closer to the newborn to increase temperature ❌ Phototherapy lights should be positioned at a safe distance to avoid overheating or burns. Temperature should be monitored, not manipulated this way.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A rationale
Soft bumper pads in the crib increase the risk of suffocation or entrapment for the newborn. The current recommendation for safe sleep is a firm mattress in a crib that meets current safety standards, with only a fitted sheet. Cribs should be bare, with no soft objects, pillows, or loose bedding, to minimize the risk of Sudden Infant Death Syndrome (SIDS).
Choice B rationale
Placing a pillow under the newborn's head significantly increases the risk of suffocation or rebreathing exhaled air, which is a major risk factor for SIDS. Newborns should always be placed on their backs on a firm sleep surface for every sleep time. The head should remain uncovered, and the pillow offers no benefit, only hazard.
Choice C rationale
Using a warm, soapy washcloth on a newborn's delicate facial skin is unnecessary and may cause irritation or dryness. Newborns typically only require a plain water wash or a mild, non-soap cleanser for their face. Soap can remove the natural protective oils and disrupt the skin's barrier function.
Choice D rationale
Setting the maximum hot water temperature to 48.8°C (120°F) is a critical home safety precaution to prevent scalding burns. Water temperatures above this level can cause third-degree burns in a matter of seconds, especially in infants and young children whose skin is thinner and more vulnerable to thermal injury.
Correct Answer is D
Explanation
Choice A rationale
Vesicles on the skin, lips, and around the eyes are characteristic findings for a herpes simplex virus (HSV) infection, which is a significant and potentially life-threatening viral infection in a newborn. Candida albicans, a fungus, typically causes superficial mucocutaneous infections and is not associated with vesicular skin lesions unless disseminated, which is rare.
Choice B rationale
A temperature of 37.5°C (99.5°F) is within the normal thermal range for a newborn; normal rectal temperature is 36.5°C to 37.5°C (97.7°F to 99.5°F). While an infection could cause fever, this specific temperature is not necessarily indicative of a Candida infection and is an expected normal finding.
Choice C rationale
Edematous red conjunctivae are classic signs of conjunctivitis (ophthalmia neonatorum), often caused by bacterial pathogens like Chlamydia trachomatis or Neisseria gonorrhoeae, acquired during passage through the birth canal. Candida albicans rarely causes ocular infection unless in immunocompromised infants.
Choice D rationale
White patches on the tongue that cannot be removed with gentle scraping are the pathognomonic sign of oral candidiasis (thrush). This is caused by an overgrowth of the yeast Candida albicans, forming a superficial pseudomembrane composed of yeast, debris, and inflammatory cells on the buccal mucosa and tongue.
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