A nurse is caring for a 1-day-old newborn who has jaundice and is receiving phototherapy. Which of the following actions should the nurse take?
Keep the infant's head covered with a cap.
Apply lotion to the newborn every 4 hr.
Give the infant 30 mL (1 oz) of glucose water every 2 hr.
Ensure that the newborn wears a diaper.
The Correct Answer is D
A. The infants’s head should not be covered while receiving phototherapy, as the skin needs to be exposed to the therapy. However, it is essential to ensure that the infant's eyes are protected from the light.
B. Applying lotion may interfere with the effectiveness of phototherapy by blocking the light’s effects and is unnecessary for managing jaundice in newborns.
C. Giving glucose water is unnecessary and may interfere with the infant's hydration and nutritional needs during phototherapy.
D. Ensuring that the newborn wears a diaper to prevent soiling of the phototherapy equipment and to allow for the monitoring of urinary output, which is an important indicator of the newborn's health during treatment.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A: This response invalidates the client's experience and may cause them to feel misunderstood or alienated.
B: This response does not address the seriousness of the client's statement and dismisses their fear.
C: This is an appropriate response because it acknowledges the client's experience without agreeing with the delusion, helping to maintain a grasp on reality.
D: While this question could be useful during a more in-depth conversation, it does not address the immediate safety concern and may not help deescalate the situation.
Correct Answer is C
Explanation
A. Referring the family to a chronic pain support group may be beneficial but does not address the immediate need to assess the child's current condition and management.
B. Requesting a change in medication from the provider may be necessary but should be based on a thorough assessment, including reviewing the child's pain diary.
C. Reviewing the child's electronic pain diary allows the nurse to gather important information about the frequency, severity, triggers, and effectiveness of current interventions for migraine headaches, guiding further assessment and management.
D. While involving the school nurse may be part of the child's care plan, it does not address the immediate need to assess the child's current condition and management.
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