A newborn is jaundiced and receivesphototherapy via ultraviolet bank lights.
An appropriate nursing intervention when caring for an infant with hyperbilirubinemia and receiving phototherapy by this method would be to:

Apply an oil-based lotion to the newborn’s skin to prevent drying and cracking.

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

Place eye shields over the newborn’s closed eyes.

Change the newborn’s position every 4 hours.

Answer and Explanation

The Correct Answer is C

Placing eye shields over the newborn’s closed eyes. This is because phototherapy can cause eye damage and irritation to the newborn, so eye protection is essential.

Choice A is wrong because oil-based lotion can increase the absorption of heat and cause burns to the newborn’s skin.

Choice B is wrong because limiting the newborn’s intake of milk can cause dehydration and increase the risk of hyperbilirubinemia.

Choice D is wrong because changing the newborn’s position every 4 hours is not frequent enough to prevent pressure ulcers and ensure even exposure to the light.

Normal ranges for bilirubin levels in newborns are 1 to 12 mg/dL for term infants and 3 to 14 mg/dL for preterm infants. Phototherapy is usually indicated when the bilirubin level exceeds 15 mg/dL for term infants and 10 mg/dL for preterm infants.

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Correct Answer is D

Explanation

An Apgar score of 10 at 1 minute after birth indicates that the infant is having no difficulty adjusting to extrauterine life but who should be assessed again at 5 minutes after birth. The Apgar score is a scoring system that evaluates the health of newborns at 1 and 5 minutes after birth based on five criteria: appearance, pulse, grimace, activity, and respiration. Each criterion is scored from 0 to 2, and the total score ranges from 0 to 10. A score of 7 to 10 is considered reassuring, a score of 4 to 6 is moderately abnormal, and a score of 0 to 3 is concerning.

Choice A is wrong because an Apgar score of 10 at 1 minute does not mean that the infant needs no further testing. The infant should still be assessed again at 5 minutes and monitored for any signs of distress or complications.

Choice B is wrong because an Apgar score of 10 at 1 minute does not indicate an infant in severe distress who needs resuscitation. An Apgar score of 0 to 3 would indicate a concerning condition that may require immediate intervention.

Choice C is wrong because an Apgar score of 10 at 1 minute does not predict a future free of neurologic problems. The Apgar score alone cannot be considered as evidence of, or a consequence of, asphyxia or brain injury; it does not predict individual neonatal mortality or neurologic outcome; and it should not be used for that purpose.

Normal ranges for each criterion are as follows:

Appearance (color): pink all over (2 points), body pink but extremities blue (1 point), blue, bluish-gray, or pale all over (0 points)
Pulse (heart rate): greater than 100 beats per minute (2 points), less than 100 beats per minute (1 point), absent (0 points)
Grimace (response to stimulation): cough or sneeze, cry and withdrawal of foot with stimulation (2 points), facial movement/grimace with stimulation (1 point), absent (0 points)
Activity (muscle tone): active movement (2 points), limbs flexed (1 point), limp or floppy (0 points)
Respiration (breathing): good, strong cry (2 points), irregular, weak crying (1 point), absent (0 points)

A. The child’s fever is usually responsive to antibiotics within 48 hours B. The principal area of involvement is the joints C. Aspirin is contraindicated D. Therapeutic management includes the administration of gamma globulin and aspirin.

Correct Answer is D

Explanation

Therapeutic management includes the administration of gamma globulin and aspirin. This is because Kawasaki disease causes inflammation in the walls of small to medium-sized blood vessels that carry blood throughout the body and can lead to complications such as coronary artery aneurysms. Gamma globulin is an intravenous immunoglobulin that can reduce the risk of these complications, and aspirin can help lower fever and inflammation.

Choice A is wrong because the child’s fever is usually not responsive to antibiotics within 48 hours. Kawasaki disease is not caused by a bacterial infection, so antibiotics are not effective.

Choice B is wrong because the principal area of involvement is not the joints. Kawasaki disease affects mainly the blood vessels, but it can also cause swelling in glands (lymph nodes) and mucous membranes inside the mouth, nose, eyes and throat. Joint pain or swelling may occur, but it is not the main feature of the disease.

Choice C is wrong because aspirin is not contraindicated. Aspirin is part of the standard treatment for Kawasaki disease, along with gamma globulin. However, aspirin should be used with caution and under medical supervision, as it can cause Reye’s syndrome in children with viral infections.

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A newborn is jaundiced and receivesphototherapy via ultraviolet bank lights. An appropriate nursing intervention when caring for an infant with hyperbilirubinemia and receiving phototherapy by this method would be to:

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

An Apgar score of 10 at 1 minute after birth would indicate a(n):

Correct Answer is D

Explanation

When caring for a child with Kawasaki disease, the nurse should understand that principle of care?

Correct Answer is D

Explanation

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A newborn is jaundiced and receivesphototherapy via ultraviolet bank lights.
An appropriate nursing intervention when caring for an infant with hyperbilirubinemia and receiving phototherapy by this method would be to: