A nurse is caring for a 2-day-old newborn who is undergoing phototherapy for treatment of hyperbilirubinemia.
Which of the following actions should the nurse take?
Provide additional hydration by offering glucose water.
Monitor the newborn’s heart rate every 2 hours.
Apply a water-based lotion to the newborn’s skin every 4 hours.
Remove the newborn from phototherapy every 2 hours for breastfeeding.
The Correct Answer is D
Choice A rationale
Providing additional hydration by offering glucose water is not recommended. Breast milk or formula should be the primary source of hydration for newborns.
Choice B rationale
Monitoring the newborn’s heart rate every 2 hours is not necessary for phototherapy. The focus should be on monitoring bilirubin levels, hydration status, and ensuring the newborn’s eyes are protected.
Choice C rationale
Applying a water-based lotion to the newborn’s skin every 4 hours is not recommended. Lotions can interfere with the effectiveness of phototherapy and may cause skin irritation.
Choice D rationale
Removing the newborn from phototherapy every 2 hours for breastfeeding is recommended. Frequent breastfeeding helps to promote bilirubin excretion and maintain hydration.
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Related Questions
Correct Answer is {"dropdown-group-1":"A","dropdown-group-2":"A"}
Explanation
The nurse should clarify the prescription forRh (D) immune globulinbecause of the client’sblood type.
Explanation:
- Rh (D) immune globulinis administered to Rh-negative mothers to prevent Rh sensitization, which can occur if the mother is Rh-negative and the baby is Rh-positive. This medication is crucial in preventing hemolytic disease of the newborn in future pregnancies.
- In this case, the client’s blood type isO+(Rh-positive). Therefore, administering Rh (D) immune globulin is unnecessary and inappropriate for this client, as it is only indicated for Rh-negative individuals.
Correct Answer is D
Explanation
Choice A rationale
Administering oxygen may help with symptoms like headache and weakness, but it does not address the underlying issue of poor circulation and potential shock. Elevating the legs is more effective in improving blood flow to vital organs.
Choice B rationale
Offering an ice pack is not appropriate for the symptoms described. The client is showing signs of shock, and an ice pack would not address the underlying issue.
Choice C rationale
Providing a warm blanket may offer comfort, but it does not address the symptoms of shock. Elevating the legs is a more direct intervention to improve circulation and stabilize the client.
Choice D rationale
Elevating the client’s legs helps improve venous return to the heart, increasing cardiac output and stabilizing blood pressure. This is a critical intervention for a client showing signs of shock.
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