A nurse is caring for a 2-day-old newborn who has a bilirubin level of 14 mg/dL (1 to 12 mg/dL) and is to begin phototherapy.
Which of the following actions should the nurse take?

Give glucose water after feedings.

Instruct the client to avoid breastfeeding during treatment.

Monitor intake and output.

Apply lotions and ointments throughout the treatment.

Answer and Explanation

The Correct Answer is C

Choice A rationale

Giving glucose water after feedings is not recommended for newborns undergoing phototherapy. Breastfeeding or formula feeding should be continued to provide adequate nutrition and hydration.

Choice B rationale

Instructing the client to avoid breastfeeding during treatment is not necessary. Breastfeeding should continue to promote bonding, provide nutrition, and help with the infant's hydration and bilirubin excretion.

Choice C rationale

Monitoring intake and output is crucial for a newborn receiving phototherapy to ensure proper hydration and assess the effectiveness of the treatment in lowering bilirubin levels.

Choice D rationale

Applying lotions and ointments throughout the treatment is not recommended, as they can interfere with the effectiveness of phototherapy. The skin should be clean and dry to maximize exposure to the phototherapy light.

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Correct Answer is A

Explanation

Choice A rationale

A respiratory rate of 12/min indicates that the respiratory depression caused by magnesium sulfate toxicity has been effectively reversed by calcium gluconate. Normal respiratory rate in adults is 12-20 breaths per minute.

Choice B rationale

Absent deep tendon reflexes indicate ongoing magnesium sulfate toxicity. Calcium gluconate administration should restore normal reflexes, not cause their absence.

Choice C rationale

Slurred speech is a sign of magnesium sulfate toxicity. Effective treatment with calcium gluconate should improve neurological function and resolve symptoms like slurred speech.

Choice D rationale

A urine output of 22 mL/hr is below the normal range and suggests renal impairment or ongoing toxicity. Effective treatment should result in an increase in urine output to within the normal range (greater than 30 mL/hr).

A. A. You might experience irregular spotting the first few months after placement of the device. B. You will need to avoid using tampons during menstrual cycles. C. You will need to sign informed consent prior to the procedure. D. The device will need to be replaced every 2 years.

Correct Answer is ["A","B","C"]

Explanation

Choice A rationale

Irregular spotting is common after the placement of an IUD as the body adjusts to the device. This is a normal side effect and typically resolves within a few months.

Choice B rationale

Avoiding tampons initially after IUD placement is advised to prevent displacement or infection. Once the IUD is properly positioned and the risk of infection decreases, tampons can generally be used.

Choice C rationale

Informed consent is required prior to IUD placement to ensure the client understands the procedure, potential risks, and benefits, ensuring an informed decision.

Choice D rationale

IUDs typically need to be replaced every 3 to 10 years, depending on the type. Replacing an IUD every 2 years is not accurate and does not align with standard medical recommendations.

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A nurse is caring for a 2-day-old newborn who has a bilirubin level of 14 mg/dL (1 to 12 mg/dL) and is to begin phototherapy.Which of the following actions should the nurse take?

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A nurse is caring for a 2-day-old newborn who has a bilirubin level of 14 mg/dL (1 to 12 mg/dL) and is to begin phototherapy.
Which of the following actions should the nurse take?