A 21-year-old mother noticed her newborn's skin turned yellowish in color on the third day postpartum.The pediatrician on duty ordered the newborn to be placed under phototherapy treatment via ultraviolet bank lights.
An appropriate nursing intervention when caring for an infant receiving phototherapy by this method would be:

Dress the newborn with light-weight material clothes.

Limit the newborn's intake of milk to prevent nausea, vomiting, and diarrhea.

Place eye shields over the newborn's closed eyes.

Apply an oil-based lotion to the newborn's skin to prevent drying.

Answer and Explanation

The Correct Answer is C

Choice A rationale

Infants receiving phototherapy under bank lights must have as much skin surface area exposed as possible to maximize the breakdown of bilirubin. Dressing the newborn in clothes, even light-weight ones, would shield the skin from the ultraviolet light, significantly reducing the treatment's efficacy. The infant should be undressed, wearing only a diaper, to allow the light to interact with the bilirubin in the subcutaneous tissues, converting it into water-soluble isomers for excretion.

Choice B rationale

Limiting milk intake is contraindicated during phototherapy because adequate hydration and nutrition are essential for the excretion of bilirubin through urine and stools. Phototherapy can increase insensible water loss through the skin, raising the risk of dehydration. Frequent feedings, usually every 2 to 3 hours, stimulate peristalsis and help clear bilirubin-rich meconium and stool from the gut, preventing the enterohepatic recirculation of bilirubin which would otherwise worsen the jaundice condition.

Choice C rationale

Protecting the infant's eyes is a critical safety intervention during phototherapy. The intense ultraviolet light from the bank lights can cause permanent damage to the retina if the eyes are not shielded. The nurse must ensure that opaque eye patches or shields are securely placed over the newborn's closed eyes before the lights are turned on. Regular assessments are necessary to ensure the patches have not slipped, which could obstruct the nares or cause corneal abrasion.

Choice D rationale

Applying oil-based lotions or creams to an infant's skin during phototherapy is dangerous because these substances can absorb heat and cause significant skin burns. Lotions also create a barrier that interferes with the light's ability to reach the skin and perform the necessary photo-oxidation and photo-isomerization of bilirubin. The newborn's skin should be kept clean and dry, and any skin irritation should be managed by adjusting the infant's position rather than using topical oils.

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Correct Answer is C

Explanation

Choice A rationale

The platypelloid pelvis is characterized by a flat shape that is widened transversely but narrow in the anteroposterior diameter. This configuration is relatively rare, occurring in less than 3 percent of women. It often leads to a persistent transverse position of the fetal head, which can significantly hinder the initiation of labor and the descent of the fetus through the pelvic inlet, making it unfavorable for a standard vaginal delivery compared to other types.

Choice B rationale

An anthropoid pelvis features an oval shape that is wider in the anteroposterior diameter than the transverse diameter. While vaginal delivery is certainly possible with this pelvic type, it often results in the fetus assuming an occiput posterior position. This can lead to a longer labor process and may require more intensive nursing interventions. It represents about 20 to 25 percent of pelvic shapes in women but is not the most ideal for birth.

Choice C rationale

The gynecoid pelvis is the classic female pelvic shape, found in approximately 50 percent of women. It features a round pelvic inlet, a spacious midpelvis, and a wide pubic arch. These anatomical characteristics provide the most optimal diameters for the fetal head to navigate the birth canal during the mechanisms of labor. Because it offers the least resistance to the descending passenger, it is clinically classified as the most favorable for a vaginal birth.

Choice D rationale

An android pelvis resembles the typical male pelvis, with a heart-shaped inlet and narrow dimensions in the midpelvis and outlet. It is found in about 20 percent of women and is associated with a higher incidence of cephalopelvic disproportion. Labor in these patients often progresses slowly and frequently requires instrumental assistance or a cesarean section because the narrow pubic arch and converged sidewalls do not easily accommodate the passage of a full-term fetus.

A. Continue to document these observations. B. Start Pitocin. C. Notify the care provider immediately. D. Insert a Foley catheter.

Correct Answer is C

Explanation

Choice A rationale

Documentation is a necessary nursing responsibility, but it is not the priority when a fetal heart rate remains dangerously low. A prolonged deceleration, where the heart rate stays at 80 beats per minute for five minutes, indicates significant fetal distress and potential hypoxia. Failing to take immediate action beyond documentation could result in fetal injury or death. Priority must be given to interventions that address the underlying cause of the bradycardia.

Choice B rationale

Pitocin is a synthetic form of oxytocin used to induce or augment labor by increasing the frequency and intensity of uterine contractions. Administering Pitocin during a prolonged fetal heart rate deceleration is contraindicated because contractions can further decrease blood flow to the placenta and worsen fetal hypoxia. The goal in this situation is to relax the uterus and improve oxygenation, not to stimulate more activity that could stress the fetus.

Choice C rationale

A fetal heart rate of 80 beats per minute for five minutes constitutes a medical emergency known as a prolonged deceleration. Normal fetal heart rate is between 110 and 160 beats per minute. Since initial nursing interventions like repositioning and oxygen did not resolve the bradycardia, the healthcare provider must be notified immediately to evaluate the need for an emergency cesarean section or other urgent medical interventions to save the fetus.

Choice D rationale

Inserting a Foley catheter may be part of the preparation for an emergency cesarean section, but it is not the immediate priority over notifying the provider. The nurse must first ensure that the medical team is aware of the critical fetal status. While a catheter helps drain the bladder to provide better surgical access, the most time-sensitive action is communicating the sustained fetal bradycardia to a physician who can order a delivery.

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Naxlex Comprehensive Predictor Exams

A nurse is reviewing the prenatal record of a laboring woman. The clinical pelvimetry notes indicate the woman has a round pelvic inlet with a spacious midpelvis and outlet. This pelvic type is most favorable for vaginal birth and is classified as:

Correct Answer is C

Explanation

Correct Answer is C

Explanation

A nurse is performing Leopold maneuvers on a woman at 36 weeks gestation. The physician wants to know if the baby is in a favorable position for vaginal delivery. Which information can the nurse obtain from this assessment? Select all that apply.

A nurse is performing a postpartum assessment on a woman who gave birth 10 days ago. The nurse palpates the fundus and finds it at the level of the symphysis pubis. Which interpretation of this finding is correct?

A nurse is counseling a woman at an obstetric and gynecology clinic for primary dysmenorrhea. Which nonpharmacologic intervention might be recommended?

A nurse is documenting a laboring woman's contractions using the external fetal monitor. Which contraction characteristics should the nurse include in the documentation? Select all that apply.

At a maternity clinic, a woman who is 32 weeks pregnant is being taught by the nurse about the danger signs of pregnancy. Which among the choices below would the nurse include?

A new mother is concerned because her 1-day-old infant spits up a small amount after feeding. She asks the nurse how to prevent this. Which instruction should the nurse provide?

After you complete your nutritional counseling for a pregnant woman, you ask her to repeat your instructions so you can assess her understanding of the instructions given. Which statement indicates that she understands the role of protein in her pregnancy?

Before discharge from the hospital, a 20-year-old postpartum woman receives instructions about breastfeeding. The woman said that her baby boy has a good sucking reflex and that she has difficulty removing her breast from her baby's mouth. Which advice by the nurse is most appropriate?