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.
Avoid stimulation.
Decrease fluid intake.
Monitor skin temperature closely.
Cover the newborn’s eyes with eye shields or patches.
Reposition the newborn every 2 hours.
Correct Answer : C,D,E
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A rationale
Inserting medication in the buccal cavity is an appropriate method for administering oral medication to an infant. The buccal cavity is the area between the cheek and gums, and medication placed here is absorbed directly into the bloodstream.
Choice B rationale
Wrapping the infant in a blanket can provide comfort and security during medication administration, making it easier for both the parent and the infant.
Choice C rationale
Positioning the infant in a supine position during oral medication administration is not safe. This position increases the risk of aspiration, which can lead to choking.
Choice D rationale
Administering medication with an oral syringe is an appropriate method for giving oral medication to an infant. It allows for accurate dosing and can be directed towards the cheek to prevent choking.
Correct Answer is A
Explanation
Choice A rationale
A bulging fontanel is a common sign of increased intracranial pressure (ICP) in infants. The fontanels, or soft spots on an infant’s head, allow for brain growth. When there is increased pressure, as in conditions that cause increased ICP, it can cause the fontanels to bulge outwards.
Choice B rationale
Insomnia is not typically associated with increased ICP in infants. Changes in consciousness, such as irritability or lethargy, may be seen, but these are not the same as insomnia.
Choice C rationale
A low-pitched cry is not typically associated with increased ICP in infants. Changes in cry might occur, but they are not specific to increased ICP4.
Choice D rationale
A positive Babinski reflex is normal in infants up to about 12 months of age. It is not specifically associated with increased ICP4.
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