The nurse is preparing to care for a newborn receiving phototherapy.
Which interventions should be included in the plan of care? Select all that apply.

Choice A rationale

Avoiding stimulation is not a necessary intervention for a newborn receiving phototherapy. Phototherapy is a treatment for jaundice where the exposure of skin to a light source converts unconjugated bilirubin molecules into water-soluble isomers that can be excreted by the usual pathways. There is no specific need to avoid stimulation during this treatment.

Choice B rationale

Decreasing fluid intake is not a recommended intervention for a newborn receiving phototherapy. In fact, adequate hydration is important during phototherapy to promote the excretion of bilirubin. Therefore, fluid intake should not be decreased.

Choice C rationale

Monitoring skin temperature closely is a necessary intervention for a newborn receiving phototherapy. The lights used in phototherapy can generate heat, so it’s important to monitor the baby’s temperature to prevent overheating.

Choice D rationale

Covering the newborn’s eyes with eye shields or patches is a necessary intervention during phototherapy. This is done to protect the baby’s eyes from the bright lights used in the treatment.

Choice E rationale

Repositioning the newborn every 2 hours is a necessary intervention during phototherapy. This helps to expose different areas of the baby’s skin to the light, which can improve the effectiveness of the treatment.

Choice A rationale

Hypertension is not typically associated with spina bifida. While it can occur in any individual based on a variety of factors such as diet, lifestyle, and genetics, it is not a direct complication of spina bifida.

Choice B rationale

Urinary tract infections are a common complication in individuals with spina bifida. This is because many people with this condition often cannot control their bladder and bowel movements, which can lead to infections. The nerves that control the bladder and bowel are often damaged in spina bifida, leading to issues with these functions and increasing the risk of urinary tract infections.

Choice C rationale

Hearing loss is not typically a complication of spina bifida. While hearing loss can occur due to a variety of reasons such as age, exposure to loud noises, and certain illnesses, it is not directly related to spina bifida.

Choice D rationale

Type 1 diabetes is not a known complication of spina bifida. Diabetes is a condition that affects the body’s ability to regulate blood sugar levels and is not directly related to the neurological and physical issues caused by spina bifida.