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 D
Explanation
Choice A rationale:
Morning sickness, which refers to nausea and vomiting during pregnancy, is a common symptom but not a definitive sign of pregnancy. It can also be caused by various other factors such as food poisoning or gastrointestinal issues. Therefore, it is not a positive sign of pregnancy.
Choice B rationale:
Quickening, which refers to the first fetal movements felt by the mother, is a subjective sign of pregnancy. It is not a definitive indication of pregnancy as it can be mistaken for other abdominal sensations. Quickening usually occurs between 18 to 22 weeks of gestation, making it a later sign and not an early positive sign of pregnancy.
Choice C rationale:
A positive pregnancy test, specifically a blood or urine test detecting human chorionic gonadotropin (hCG), is a reliable indicator of pregnancy. However, it is a biochemical sign and not a physical sign. It does not directly confirm the presence of the fetus or its well-being, making it less specific than auscultating the fetal heartbeat.
Choice D rationale:
Fetal heartbeat auscultated with Doppler/fetoscope is a positive sign of pregnancy. The healthcare provider can hear the fetal heartbeat using a Doppler ultrasound device or fetoscope, confirming the presence of a viable pregnancy. This sign is considered positive because it directly indicates the presence of a developing fetus, providing reassurance about the pregnancy status. Fetal heartbeat can usually be detected around 10 to 12 weeks of gestation.
Correct Answer is C
Explanation
Choice A rationale:
A stat magnesium sulfate level (Choice A) is unnecessary in this situation. The symptoms described - increased temperature, pulse rate, and blood pressure, along with absent deep tendon reflexes - indicate magnesium sulfate toxicity. Discontinuing the infusion and managing the symptoms take precedence over checking the magnesium sulfate level.
Choice B rationale:
Administering oxygen (Choice B) is important for maintaining the patient's oxygenation levels, but it does not address the magnesium sulfate toxicity. The primary intervention should be to discontinue the infusion and manage the symptoms.
Choice C rationale:
Discontinuing the magnesium sulfate infusion (Choice C) is the correct action in this situation. The symptoms, including absent deep tendon reflexes and the patient's complaint of thirst and warmth, indicate magnesium sulfate toxicity. Stopping the infusion is crucial to prevent further complications.
Choice D rationale:
Hydralazine (Choice D) is an antihypertensive medication and is not the appropriate intervention for magnesium sulfate toxicity. Managing magnesium sulfate toxicity involves discontinuing the infusion and providing supportive care.
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