Which of the following would the nurse include in the plan of care for a newborn receiving phototherapy? Select one:

Applying Vaseline or lotion to newborn to maximize light absorption.

Reducing the amount of ﬂuid intake to 8 ounces daily.

Keeping the newborn in the supine position.

Feeding every 3 hours to maximize intake of ﬂuids and output.

Answer and Explanation

The Correct Answer is D

Choice A Reason: Applying Vaseline or lotion to newborn to maximize light absorption. This is an incorrect answer that indicates a contraindicated and harmful intervention that can interfere with phototherapy. Applying Vaseline or lotion to newborn can create a barrier or a reﬂective surface that can reduce the exposure and penetration of light to the skin, which can decrease the efficacy of phototherapy. Applying Vaseline or lotion to newborn can also cause skin irritation, infection, or burns, as it can trap heat and moisture under the light source.

Choice B Reason: Reducing the amount of ﬂuid intake to 8 ounces daily. This is an incorrect answer that suggests a detrimental and dangerous intervention that can impair phototherapy. Reducing the amount of ﬂuid intake to 8 ounces daily can cause dehydration, hypoglycemia, or electrolyte imbalance in newborns, which can worsen jaundice and increase the risk of complications such as kernicterus (brain damage due to high bilirubin levels). Reducing the amount of ﬂuid intake to 8 ounces daily can also decrease the excretion of bilirubin through urine or stool, which can counteract the eﬀect of phototherapy.

Choice C Reason: Keeping the newborn in the supine position. This is an incorrect answer that implies an incomplete and inadequate intervention that can limit phototherapy. Keeping the newborn in the supine position is a nursing action that involves placing the newborn on their back, which can expose their anterior body surface to light.

However, keeping the newborn in the supine position alone is not sufficient for phototherapy, as it does not expose their posterior body surface to light. The nurse should also reposition the newborn frequently to expose diﬀerent body parts to light, such as their sides or abdomen.

Choice D Reason: Feeding every 3 hours to maximize intake of ﬂuids and output. This is because feeding every 3 hours is a nursing intervention that can enhance the eﬀectiveness and safety of phototherapy, which is a treatment that uses blue or white light to reduce the level of bilirubin in the blood. Bilirubin is a yellow pigment that is produced when red blood cells are broken down, which can cause jaundice (yellowish discoloration of the skin and mucous membranes) if it accumulates in excess. Phototherapy works by converting bilirubin into a water-soluble form that can be excreted through urine or stool. Feeding every 3 hours can increase the intake of ﬂuids and calories, which can promote hydration, nutrition, and elimination of bilirubin.

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Correct Answer is B

Explanation

Choice A Reason: Vascular spider veins. This is an incorrect answer that refers to a diﬀerent skin change that occurs during pregnancy, which aﬀects the blood vessels, not the pigment. Vascular spider veins are small red or purple clusters of blood vessels that appear on the skin, especially on the face, neck, chest, or legs. Vascular spider veins are caused by increased blood volume and hormonal changes, which dilate and rupture the capillaries. Vascular spider veins are harmless and usually disappear after delivery.

Choice B Reason: Linea nigra. This is because linea nigra is a term that refers to a darkened vertical line that appears on the abdomen during pregnancy, which runs from the umbilicus to the pubis. Linea nigra is caused by increased production of melanin, which is a pigment that gives color to the skin and hair. Linea nigra is more common and noticeable in women with darker skin tones, and it usually fades after delivery.

Choice C Reason: Melasma. This is an incorrect answer that refers to a diﬀerent skin change that occurs during pregnancy, which aﬀects the pigment, but not in a linear patern. Melasma is a term that refers to patches of brown or gray-brown discoloration that appear on the face, especially on the forehead, cheeks, nose, or upper lip. Melasma is also caused by increased production of melanin, but it is inﬂuenced by sun exposure and genetic factors. Melasma is also known as chloasma or the mask of pregnancy, and it may persist after delivery.

Choice D Reason: Striae gravidarum. This is an incorrect answer that refers to a diﬀerent skin change that occurs during pregnancy, which aﬀects the connective tissue, not the pigment. Striae gravidarum are stretch marks that appear on the skin, especially on the abdomen, breasts, hips, or thighs. Striae gravidarum are caused by rapid growth and stretching of the skin, which damage the collagen and elastin fibers. Striae gravidarum are initially red or purple, but they fade to white or silver after delivery.

A. Central cyanosis and poor tone. B. Heart rate of 160 beats per minute and spitting up mucus. C. Crying with respirations of greater than 60 breaths per minute. D. Blue hands and feet but lips that are slowly pinking up.

Correct Answer is A

Explanation

Choice A Reason: Central cyanosis and poor tone. These are signs of hypoxia and asphyxia in newborns, which indicate a need for resuscitation. Central cyanosis means bluish discoloration of the skin or mucous membranes around the mouth, nose, or eyes. Poor tone means limpness or lack of muscle activity.

Choice B Reason: Heart rate of 160 beats per minute and spitting up mucus. These are not signs of hypoxia or asphyxia in newborns, but rather normal findings or minor issues. A normal heart rate for a newborn ranges from 120 to 160 beats per minute. Spitting up mucus may be due to excess secretions or swallowing amniotic ﬂuid, which can be cleared by suctioning or burping.

Choice C Reason: Crying with respirations of greater than 60 breaths per minute. These are not signs of hypoxia or asphyxia in newborns, but rather normal or expected findings. Crying indicates that the newborn has a patent airway and adequate lung expansion. Respirations of greater than 60 breaths per minute may be normal for a newborn in transition or due to transient tachypnea, which usually resolves within a few hours.

Choice D Reason: Blue hands and feet but lips that are slowly pinking up. These are not signs of hypoxia or asphyxia in newborns, but rather a common condition called acrocyanosis. Acrocyanosis means bluish discoloration of the hands and feet due to poor peripheral circulation in response to cold exposure or stress. It does not aﬀect oxygenation or ventilation and usually disappears within 24 to 48 hours after birth.

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Which of the following would the nurse include in the plan of care for a newborn receiving phototherapy? Select one:

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is B

Explanation

Correct Answer is A

Explanation

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