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 C
Explanation
A. Placing the client on her left lateral side is an appropriate intervention for variable or late decelerations, which may indicate uteroplacental insufficiency or cord compression, but it is not required for early decelerations, as these are generally benign and related to fetal head compression.
B. Checking maternal vital signs is part of routine monitoring, but it is not the priority intervention specifically related to early decelerations. Maternal vital signs are unlikely to immediately change the interpretation or management of early decelerations.
C. Documenting the findings is appropriate because early decelerations are a normal, expected pattern during labor. They are characterized by gradual decreases in fetal heart rate that mirror uterine contractions, typically reaching the nadir at the peak of the contraction. This pattern reflects fetal head compression as the fetus descends through the birth canal and does not indicate fetal compromise. No immediate interventions are required other than continued monitoring.
D. Applying oxygen is generally reserved for situations where there is fetal distress, such as with late or variable decelerations accompanied by abnormal baseline or variability. Early decelerations are not caused by fetal hypoxia, so oxygen administration is unnecessary.
Correct Answer is C
Explanation
A. This is not necessary in this situation because a heart rate of 130 beats per minute is within the normal range for a term newborn. Immediate notification of the provider is required only for abnormal heart rates (tachycardia >160 bpm, bradycardia <100 bpm), irregular rhythms, or other signs of compromise, such as pallor, cyanosis, or poor perfusion.
B. Verification may be useful when an abnormal or unexpected finding occurs, but it is not required for a heart rate that is clearly within the normal range. Routine newborn assessments are reliable when performed properly.
C. The normal resting heart rate for a full-term newborn ranges from 110 to 160 beats per minute. A heart rate of 130/min falls squarely within this range, indicating adequate cardiovascular function. Documentation should include the apical heart rate, method of measurement, time of assessment, and any relevant observations (e.g., skin color, activity, respiratory effort). Proper documentation ensures continuity of care and provides a baseline for ongoing assessments.
D. This is unnecessary. There are no signs of distress or abnormal findings in this scenario that would warrant NICU admission. Routine monitoring and care in the newborn nursery or with the mother are appropriate.
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