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.

Answer and Explanation

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.

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Correct Answer is A

Explanation

Choice A rationale

Maintaining elbow restraints on the toddler after a cleft palate repair is a common practice. This is done to prevent the child from touching the surgical site and causing damage to the delicate repair.

Choice B rationale

Providing soft foods for the toddler after a cleft palate repair may seem like a good idea, but it is not the most appropriate intervention immediately after surgery. The surgical site in the mouth needs time to heal, and introducing foods too soon could disrupt the healing process.

Choice C rationale

Suctioning the toddler’s nose and mouth every hour after a cleft palate repair is not typically recommended. This could potentially damage the surgical site and disrupt the healing process.

Choice D rationale

Giving the toddler a hard-tipped sippy cup to drink liquids after a cleft palate repair is not typically recommended. The hard tip could potentially damage the surgical site and disrupt the healing process.

A. Inserts medication in the buccal cavity. B. Wraps infant in a blanket. C. Positions infant in a supine position. D. Administers medication with an oral syringe.

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.

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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.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is contributing to the plan of care of a 14-month-old toddler who is 24 hr postoperative following a cleft palate repair.Which of the following interventions should the nurse include in the plan?

Correct Answer is A

Explanation

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Correct Answer is C

Explanation

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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.