A newborn is jaundiced and receiving phototherapy 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
Choice A rationale:
Applying oil-based lotion is not recommended during phototherapy as it can block the pores and reduce the effectiveness of the therapy. The baby's skin should be exposed to the light as much as possible to treat hyperbilirubinemia effectively.
Choice B rationale:
Limiting the newborn's intake of milk is not appropriate. Adequate hydration and nutrition are essential for infants, especially those undergoing phototherapy. Dehydration can worsen jaundice, so the baby should be encouraged to feed frequently.
Choice C rationale:
Placing eye shields over the newborn's closed eyes is essential during phototherapy. Exposure to high-intensity light can damage the baby's eyes, so protecting the eyes with shields is necessary.
Choice D rationale:
Changing the newborn's position every 2-3 hours is recommended during phototherapy. This helps ensure that all parts of the baby's skin receive equal exposure to the light, maximizing the effectiveness of the treatment.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A rationale:
Ribbon-like stools are not characteristic of intussusception. Intussusception is a medical emergency where one portion of the intestine invaginates or telescopes into another. This condition can lead to intestinal obstruction and compromised blood flow, causing severe abdominal pain, vomiting, and bloody stools. The characteristic stool appearance associated with intussusception is "currant jelly" stools. These stools contain mucus, blood, and sloughed mucosal tissue, giving them a characteristic dark, sticky, and jelly-like appearance. This occurs due to the mixture of blood and mucus within the intestines.
Choice B rationale:
Hard stools positive for guaiac indicate the presence of occult blood in the stool, but this finding is not specific to intussusception. Occult blood in the stool can be a sign of gastrointestinal bleeding from various causes, such as ulcers, gastritis, or colorectal polyps. It is not a characteristic feature of intussusception.
Choice D rationale:
Loose, foul-smelling stools are nonspecific and can occur due to various gastrointestinal disorders, dietary issues, or infections. This description does not specifically indicate intussusception.
Correct Answer is A
Explanation
Choice A rationale:
A brilliant, uniform red reflex observed during a funduscopic examination is a normal finding. It indicates the absence of any abnormalities in the retina or lens. A normal red reflex is essential in ruling out serious conditions such as retinoblastoma, cataracts, or other eye abnormalities.
Choice B rationale:
An abnormal red reflex, especially if it is not uniform and brilliant, could indicate underlying eye conditions and would require referral to an ophthalmologist for further evaluation. However, in this scenario, the description provided indicates a normal finding, making this choice incorrect.
Choice C rationale:
A uniform red reflex does not suggest a possible visual defect that requires vision screening. A normal red reflex indicates the absence of significant visual abnormalities, making this choice incorrect.
Choice D rationale:
Small hemorrhages in the eye would not present as a brilliant, uniform red reflex. Hemorrhages typically appear as dark spots or patches and would be an abnormal finding requiring further evaluation. This choice is incorrect in the context of the described scenario.
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