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. Using a child as an interpreter can be inappropriate and may not ensure accurate communication, especially for sensitive topics such as medical history and symptoms.
B. While involving the client's partner may seem helpful, it may not ensure accurate translation, and the partner may not be proficient in medical terminology.
C. Requesting a female interpreter through the facility ensures accurate and confidential communication while respecting the client's cultural preferences and privacy.
D. While asking a nursing student who speaks the same language as the client may seem convenient, it may not ensure accurate translation, and the student may not have the necessary training in medical interpretation.
Correct Answer is C
Explanation
A. Reevaluating for an ET cuff leak is important but not the immediate priority when the cause of the alarm is unknown, and the client is in distress. It is more important to ensure the client is receiving adequate ventilation.
B. Assessing for disconnected tubing is essential, but if the cause of the high-pressure alarm is unclear and the client is in distress, manual ventilation should take precedence.
C. When a high-pressure alarm sounds on a mechanical ventilator and the cause is not immediately identifiable, the nurse should prioritize the client's safety by delivering breaths manually with a resuscitation bag. This ensures that the client continues to receive oxygen while troubleshooting the ventilator issue. Manual ventilation is crucial in preventing hypoxia during periods of mechanical failure or when the cause of the alarm cannot be quickly identified.
D. Decreasing the ventilator flow rate may not address the underlying issue causing the high-pressure alarm and could potentially worsen the situation. Immediate manual ventilation is the safest action.
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