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 D

Explanation

Choice A Reason: "My baby will always be smaller than other babies his age." This is an incorrect answer that indicates a misconception or pessimism about SGA newborns. SGA newborns may not always be smaller than other babies their age, as they may catch up in growth and development with appropriate nutrition and care. SGA newborns may have diﬀerent growth paterns depending on the cause and timing of their growth restriction.

Choice B Reason: "My baby will be okay as long as he has frequent feedings." This is an incorrect answer that indicates an oversimplification or optimism about SGA newborns. SGA newborns may not be okay with just frequent feedings, as they may have other problems or complications that require medical atention and intervention. SGA newborns may have increased nutritional needs and feeding difficulties due to low birth weight, poor suck-swallow coordination, or oral aversion.

Choice C Reason: "My baby will need to stay in the hospital until he weighs 5 pounds." This is an incorrect answer that indicates a misunderstanding or confusion about SGA newborns. SGA newborns may not need to stay in the hospital until they weigh 5 pounds, as they may be discharged earlier or later depending on their condition and readiness for home care. SGA newborns may have diﬀerent criteria for discharge based on their gestational age, weight gain, feeding tolerance, temperature stability, and absence of complications.

Choice D Reason: "My baby can get cold easily, may have low blood sugar, and may have trouble breathing." This is because this statement by the parents indicates that they understand some of the common problems and complications that SGA newborns may face. SGA newborns are those who weigh less than the 10th percentile for their gestational age, which can be due to intrauterine growth restriction (IUGR) or constitutional factors. SGA newborns may have difficulties with thermoregulation, glucose metabolism, and respiratory function due to inadequate fat stores, glycogen reserves, and surfactant production.

A. Partial. B. Complete. C. Marginal. D. Low-lying.

Correct Answer is D

Explanation

Choice A Reason: Partial placenta previa is a condition where the placenta partially covers the cervix. It usually does not resolve and may cause bleeding and complications during labor and delivery.

Choice B Reason: Complete placenta previa is a condition where the placenta completely covers the cervix. It is a serious condition that requires cesarean delivery and may cause life-threatening hemorrhage.

Choice C Reason: Marginal placenta previa is a condition where the edge of the placenta reaches the margin of the cervix. It may also cause bleeding and complications during labor and delivery.

Choice D Reason: Low-lying placenta previa is a condition where the placenta is near the cervix, but not covering it. It may resolve spontaneously as the uterus grows and the placenta moves upward.

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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

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Correct Answer is D

Explanation

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Correct Answer is D

Explanation

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