A newborn develops hyperbilirubinemia when 24 hours old and is prescribed phototherapy.
Which measure is an important part of this newborn’s care plan?

Elevate the head of the infant’s crib.

Apply a water-soluble ointment to the infant’s eyes.

Dress the infant in a long-sleeved shirt.

Keep the infant well hydrated.

Answer and Explanation

The Correct Answer is D

he correct answer is choice D. Keep the infant well hydrated.This is because phototherapy can cause dehydration due to increased insensible water loss from the skin. Hydration helps the infant excrete bilirubin in urine and stool.

Choice A is wrong because elevating the head of the infant’s crib does not affect bilirubin levels or phototherapy effectiveness.

Choice B is wrong because applying a water-soluble ointment to the infant’s eyes can interfere with eye protection and cause eye irritation. The infant’s eyes should be covered with opaque patches or goggles during phototherapy to prevent eye damage.

Choice C is wrong because dressing the infant in a long-sleeved shirt reduces the amount of skin exposed to light and decreases the efficacy of phototherapy. The infant should be undressed except for a diaper and eye protection during phototherapy.

Normal ranges for bilirubin levels vary depending on the age of the infant, the type of jaundice, and the method of measurement. Generally, bilirubin levels above 25 mg/dL are considered dangerous and require urgent treatment.

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Correct Answer is B

Explanation

The correct answer is choice B. Apply ice to her perineal area.This is because ice can help reduce swelling and pain in the episiotomy wound, which is a cut made in the tissue between the vagina and anus during childbirth.Ice should be applied for the first 24 to 48 hours after delivery.

Choice A is wrong because Kegel exercises, which involve contracting and relaxing the pelvic floor muscles, are not recommended for the first 12 hours after an episiotomy.They can increase blood flow and inflammation in the area, and may interfere with healing.

Choice C is wrong because keeping her hips slightly elevated can cause pressure on the episiotomy wound and increase discomfort.It can also affect blood circulation and drainage in the area.

Choice D is wrong because observing her perineal area for signs of infection is not a nursing action that should be included in her plan of care for the first 12 hours.Infection is rare in episiotomy wounds, and signs of infection usually appear after 24 hours or later.However, the nurse should teach the patient how to keep the area clean and dry, and when to report any signs of infection, such as fever, pus, or foul-smelling discharge.

Normal ranges for episiotomy healing are:

• Stitches dissolve within 2 to 4 weeks

• Pain and swelling subside within a few days to a week

• Wound heals completely within 4 to 6 weeks

A. “I will use one breast at each feeding and switch to the second breast at the next feeding.”. B. “I will rub breast milk into my nipple.”. C. “I will wash my nipples with water but no soap, and I will let them air dry.”. D. “I will place warmed tea bags on my nipples.”. E. “I will place warmed tea bags on my nipples.”.

Correct Answer is D

Explanation

The correct answer is choice D. Placing warmed tea bags on the nipples is not a recommended method to avoid nipple soreness while breastfeeding.Tea bags can cause dryness and cracking of the nipples, which can increase the risk of infection and pain.

Choice A is wrong because it is better to use both breasts at each feeding and switch the starting breast at each feeding.This helps to ensure adequate milk production and drainage.

Choice B is correct because rubbing breast milk into the nipple can help to moisturize and protect the nipple from infection.Breast milk has antibacterial and healing properties.

Choice C is correct because washing the nipples with water but no soap can help to prevent irritation and dryness of the nipples.

Soap can remove the natural oils that protect the skin.Letting the nipples air dry can also help to prevent fungal growth.

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A newborn develops hyperbilirubinemia when 24 hours old and is prescribed phototherapy. Which measure is an important part of this newborn’s care plan?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A patient had an episiotomy during her delivery. Which nursing action should be included in her plan of care for the first 12 hours?

Correct Answer is B

Explanation

The nurse instructs a class of postpartum women on methods to avoid nipple soreness while breastfeeding. Which comment by a class participant indicates the need for further instruction?

Correct Answer is D

Explanation

he nurse instructs a woman who is attending the infertility clinic about strategies designed to facilitate conception. Which statement by the patient would indicate that she understands the instructions?

A patient diagnosed with preeclampsia is admitted to the hospital and prescribed magnesium sulfate therapy. What is the purpose of administering magnesium sulfate to this patient?

A patient who is attending a family planning clinic is instructed in breast self-examination by a nurse. Which statement by the patient would indicate that she understands the instructions?

When assessing a newborn, which is the best method for the nurse to use to elicit the Moro reflex?

A client who is twO weeks postpartum calls the office and tells a nurse, "l am havinga small amount of brownish discharge from my vagina." Which response is appropriate for the nurse to make?

On her second postpartum day, the mother of a newborn says, “The doctor says the baby has physiologic jaundice. Even though it is supposed to be normal, I don’t understand why it occurs.” Which fact regarding physiologic jaundice should form the basis of the nurse’s response?

A newborn develops hyperbilirubinemia when 24 hours old and is prescribed phototherapy.
Which measure is an important part of this newborn’s care plan?