A nurse is assessing a newborn who is receiving dual phototherapy via overhead lights and a fiberoptic pad for the treatment of hyperbilirubinemia. Which of the following actions should the nurse take?
Maintain therapy with the fiber optic pad while having the parent hold the newborn during feedings.
Discontinue the overhead lights when the newborn has three seedy stools within 2 hr.
Swaddle the newborn in a light blanket before placing them on the fiber optic pad.
Determine the positioning of overhead lights by assessing the newborn's axillary temperature.
The Correct Answer is A
Choice A reason: Maintaining therapy with the fiber optic pad while allowing parental holding during feedings is correct because it ensures continuous treatment while promoting bonding and feeding. Fiberoptic phototherapy pads are safe to use during holding, and they do not interfere with feeding. This approach balances effective bilirubin reduction with essential parent-infant interaction, which supports emotional well-being and breastfeeding success.
Choice B reason: Discontinuing overhead lights based on stool frequency is incorrect. Increased stooling is a common effect of phototherapy due to bilirubin excretion, but it is not a criterion for discontinuation. Therapy is guided by bilirubin levels and clinical assessment, not stool count. Stopping therapy prematurely could result in rebound hyperbilirubinemia.
Choice C reason: Swaddling the newborn before placing them on the fiber optic pad is inappropriate because swaddling blocks light exposure to the skin, reducing the effectiveness of phototherapy. Direct skin exposure is necessary for maximum bilirubin breakdown.
Choice D reason: Determining the positioning of overhead lights by assessing axillary temperature is incorrect. Temperature monitoring is important to prevent overheating, but light positioning is determined by distance and angle to maximize skin exposure, not by temperature readings.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A reason: Ambulation promotes peristalsis and reduces postoperative complications, but it should not be encouraged before assessing the underlying cause of nausea and pain. Without assessment, ambulation could worsen discomfort or mask complications.
Choice B reason: Inserting an NG tube is an invasive intervention reserved for confirmed cases of bowel obstruction or severe ileus. Performing this without assessment risks unnecessary trauma and patient distress.
Choice C reason: Auscultating for bowel sounds is the priority because it provides critical information about gastrointestinal motility and potential complications such as ileus or obstruction. Assessment must precede interventions to ensure safety and appropriateness of care.
Choice D reason: Administering an antiemetic addresses symptoms but not the underlying cause. Symptom relief without assessment could delay recognition of serious complications.
Correct Answer is B
Explanation
Choice A reason: Bleeding during peritoneal dialysis may cause the dialysate to appear pink or red, but it does not cause cloudiness. Therefore, this option is incorrect.
Choice B reason: Cloudy dialysate outflow is a classic sign of peritonitis, which is the most common and serious complication of peritoneal dialysis. Peritonitis occurs due to infection within the peritoneal cavity, often introduced during catheter handling. The cloudiness is caused by the presence of white blood cells and bacteria in the dialysate. This makes option B the correct answer.
Choice C reason: Poor dialysate flow is usually due to mechanical issues such as catheter malposition, constipation, or obstruction. It results in reduced or absent drainage but does not cause cloudiness. Thus, this option is incorrect.
Choice D reason: Fibrin clot formation can obstruct the catheter and reduce dialysate flow, but it does not cause the effluent to appear cloudy. Instead, fibrin strands may be visible in the fluid. This option is incorrect because it does not explain the cloudy appearance.
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