A nurse is caring for a 36-hr old infant.
For each nursing action, click to specify if the action is indicated or contraindicated for the newborn.
Apply lotion to skin every 4 hr.
Supplement feeding with sterile water.
Brestfeed every 2 to 3 hr.
Cover newborn's eyes with a shield.
Dress in only a diaper.
The Correct Answer is {"A":{"answers":"B"},"B":{"answers":"B"},"C":{"answers":"A"},"D":{"answers":"A"},"E":{"answers":"A"}}
A. Applying lotion to the skin is contraindicated during phototherapy because it can interfere with the effectiveness of the therapy by blocking the light from reaching the skin. B. Supplementing feeding with sterile water is contraindicated because it can decrease the newborn's intake of breast milk or formula, which is essential for hydration and nutrition, especially during phototherapy. C. Breastfeeding is indicated and encouraged every 2 to 3 hours because it helps to maintain hydration and promotes bilirubin excretion, which can help in reducing jaundice levels. D. Covering the newborn's eyes with a shield is indicated during phototherapy to protect the eyes from the bright lights used in the treatment, which can potentially damage the retina and cause eye problems. E. Dressing the newborn in only a diaper is indicated during phototherapy to maximize the exposure of the skin to the light, which enhances the effectiveness of the treatment in reducing bilirubin levels.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. A blood pressure reading of 150/92 mm Hg is indicative of hypertension, a symptom of preeclampsia, but it is not a therapeutic effect of magnesium sulfate.
B. A flushed face is not a therapeutic effect of magnesium sulfate and may indicate adverse effects such as magnesium toxicity.
C. A pulse rate of 100/min is within the normal range and is not a specific therapeutic effect of magnesium sulfate.
D. Negative clonus, assessed by dorsiflexing the client's foot and observing for absence of rhythmic oscillations or beats, indicates a therapeutic level of muscle relaxation provided by magnesium sulfate to prevent seizures in clients with preeclampsia
Correct Answer is C
Explanation
A. This task pertains more to secondary prevention, which aims to detect and treat HIV early through screenings and interventions.
B. This task is related to primary prevention, which aims to prevent HIV transmission through education and immunizations.
C. Tertiary prevention focuses on managing and reducing the impact of a disease or condition to prevent complications and promote quality of life. Using an electronic
messaging system to remind clients to take medications aligns with tertiary prevention by helping to manage HIV and prevent disease progression.
D. This task is more aligned with primary prevention, focusing on promoting healthy behaviors to prevent HIV transmission and disease development.
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