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
Performing the most invasive assessment first can cause distress and fear in a preschooler. It’s generally recommended to start with less invasive procedures to build trust and cooperation.
Choice B rationale
Separating a child from their caregiver during an examination can cause anxiety and fear. It’s often beneficial to have the caregiver present during the examination to provide comfort and reassurance.
Choice C rationale
Allowing a child to role-play using miniature equipment can help alleviate fears and anxieties about the examination. It gives the child a sense of control and understanding of what to expect.
Choice D rationale
While it’s important to explain procedures to a child, using medical terminology can confuse and scare them. It’s better to use simple, age-appropriate language that the child can understand.
Correct Answer is ["B","C","D","E"]
Explanation
Choice A rationale
Asking the guardians to leave during the procedure is not recommended. The presence of a familiar person can provide comfort and reduce anxiety for the toddler during a stressful procedure.
Choice B rationale
Performing the procedure with the child in his bed can provide a sense of security and familiarity, which can help reduce anxiety and fear.
Choice C rationale
Using the child’s favorite toy to explain or distract during the procedure can help the child understand what to expect and provide a sense of control.
Choice D rationale
Applying lidocaine and prilocaine (EMLA) Cream to 2-3 potential insertion sites can help numb the area and reduce pain during the procedure.
Choice E rationale
Allowing the child to make one choice regarding the procedure can provide a sense of control and cooperation.
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