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 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.
Correct Answer is A
Explanation
A. Administering vancomycin over a longer infusion time, such as 60 minutes, can help reduce the risk of adverse reactions, such as red man syndrome or nephrotoxicity. Slower infusion rates allow for better tolerance of the medication.
B. Vancomycin should be diluted appropriately before administration to reduce the risk of infusion-related reactions.
C. Lidocaine is not typically used prior to vancomycin administration. The use of lidocaine would be more relevant for local anesthesia, not for systemic medication administration like vancomycin.
D. Trough levels are typically obtained just before the next dose of vancomycin is due, not immediately after the infusion.
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