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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
choice D. Monitor blood glucose levels frequently and observe closely for signs of hypoglycemia. This is because a macrosomic infant (a newborn who’s much larger than average) is at risk of developing low blood sugar levels after birth, especially if the mother has diabetes. Hypoglycemia can cause neurological damage in the newborn, so it is important to detect and treat it promptly.
Choice A is wrong because leaving the infant in the room with the mother without monitoring the blood glucose levels may miss signs of hypoglycemia and delay treatment.
Choice B is wrong because taking the infant immediately to the nursery may separate the infant from the mother and interfere with breastfeeding, which can help prevent hypoglycemia.
Choice C is wrong because performing a gestational age assessment to determine whether the infant is large for gestational age is not urgent and does not address the risk of hypoglycemia.
Normal ranges for blood glucose levels in term infants are 2.6 mmol/L or higher at any time. A blood glucose level of 2.5 mmol/L or less is considered hypoglycemic.
Correct Answer is C
Explanation
Bacteria that synthesize vitamin K is not present in the newborn’s intestinal tract. Vitamin K is essential for blood clotting, and newborns are at risk of bleeding problems due to their lack of vitamin K. Therefore, vitamin K is given by injection to prevent hemorrhagic disease in the newborn.
Choice A is wrong because most mothers do not have a diet deficient in vitamin K, and vitamin K deficiency in newborns is not related to the maternal diet.
Choice B is wrong because vitamin K does not prevent the synthesis of prothrombin in the liver, but rather enhances it. Prothrombin is a clotting factor that requires vitamin K for its production.
Choice D is wrong because the supply of vitamin K is not inadequate for at least 3 to 4 months, but rather for a few days until the newborn’s intestinal bacteria start producing it.
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