A newborn is jaundiced and is receiving phototherapy. What is the most appropriate nursing intervention when caring for an infant with hyperbilirubinemia and receiving phototherapy?
Limit fluid intake to prevent diarrhea
Apply eye shields to protect the infant's eyes
Applying an oil-based lotion to the newborn's skin to prevent dying and cracking
Changing the newborn's position every 12 hours
The Correct Answer is B
A. Fluid intake should not be limited during phototherapy. In fact, maintaining adequate hydration is important because phototherapy can increase insensible fluid losses through the skin. Limiting fluids could worsen dehydration and hyperbilirubinemia.
B. Applying eye shields is essential during phototherapy to protect the newborn’s eyes from the harmful effects of light exposure, including retinal damage. The shields should be positioned correctly and checked frequently to ensure proper fit and safety. This is a primary nursing intervention during phototherapy.
C. Oil-based lotions should be avoided during phototherapy because they can absorb heat and cause skin burns. Newborn skin should be kept clean and dry; mild, water-based moisturizers may be used if necessary after phototherapy.
D. The newborn’s position should be changed frequently, usually every 2–3 hours, not every 12 hours. Frequent repositioning ensures that all areas of the body are exposed to the light, maximizing bilirubin breakdown and preventing pressure sores.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. Emptying surgical drains is an important part of postoperative care and should be performed as instructed to prevent fluid accumulation and infection. This activity is safe and encouraged.
B. Progressive arm exercises are recommended to maintain shoulder mobility and prevent stiffness or lymphedema. These exercises should be done gradually according to the nurse’s instructions.
C. Lifting less than 2 lbs is safe and typically recommended early in the postoperative period to avoid strain on the surgical site.
D. Wearing clothing with tight sleeves on the operative side should be avoided because tight clothing can restrict circulation, increase swelling, and elevate the risk of lymphedema. Patients are advised to wear loose, comfortable clothing to support proper healing and reduce complications.
Correct Answer is D
Explanation
A. Suggesting that further testing is needed implies that the score is abnormal or inconclusive. A BPP score of 8 out of 10 is generally considered normal, indicating that the fetus is well-oxygenated and not showing signs of compromise, so immediate further testing is not indicated.
B. While an obstetric specialist may review BPP results as part of routine care, the nurse should first provide accurate, reassuring information about the score. This response could cause unnecessary anxiety.
C. Immediate delivery by cesarean is not indicated for a BPP score of 8. Cesarean delivery is usually considered for scores of 4 or less, which indicate significant fetal compromise.
D. The test results are within normal limits is correct. A BPP evaluates fetal breathing movements, body movements, muscle tone, amniotic fluid volume, and nonstress test results, each scored 0–2. A total of 8–10 indicates a healthy fetus with no evidence of acute distress. This response reassures the client and accurately reflects the meaning of her BPP score.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.