A nurse is caring for a 1-week-old newborn who has hyperbilirubinemia and is being treated with phototherapy. Which of the following actions should the nurse take?
Check the newborn's eyes every 8 hr.
Place mittens on the newborn's hands.
Monitor the newborn's temperature every 2 hr.
Apply lotion to the newborn's skin.
The Correct Answer is C
Rationale:
A. Checking the newborn's eyes every 8 hours is not necessary for the management of hyperbilirubinemia or phototherapy.
B. Placing mittens on the newborn's hands is unrelated to the management of hyperbilirubinemia or phototherapy.
C. Monitoring the newborn's temperature every 2 hours is essential during phototherapy because infants are at risk of hypothermia due to increased heat loss from the lights.
D. Applying lotion to the newborn's skin is not recommended during phototherapy as it can interfere with the effectiveness of the lights.
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Related Questions
Correct Answer is D
Explanation
Rationale:
A. The child's throat pain is expected post-tonsillectomy and can be managed using analgesics or an ice collar. However, this is not a priority finding compared to frequent swallowing which may indicate bleeding which is a life-threatening complication of tonsillectomy.
B. Refusing clear liquids may indicate discomfort but is not as urgent as a potential increase in throat pain.
C. Crying often may be a response to discomfort but does not necessarily indicate a complication requiring immediate intervention.
D. This assessment finding indicates that the child might have bleeding in the throat, which is a life-threatening complication of tonsillectomy. The nurse should
Correct Answer is C
Explanation
A. Pediculosis capitis (head lice) does not require droplet precautions.
B. Viral conjunctivitis (pink eye) is typically spread through direct contact or contact with contaminated surfaces, not droplets.
C. Seasonal influenza is a respiratory illness that can spread through droplets when the infected person coughs or sneezes, necessitating droplet precautions.
D. Hepatitis A is primarily spread through the fecal-oral route and does not require droplet precautions.
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