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A nurse is caring for a newborn

Exhibits
Which of the following statements should the nurse include in the plan of care for the baby

A.

"Your baby needs to be repositioned every 2 to 3 hours while under the lights."

B.

"Your baby's eyes will be covered with an eye shield during therapy."

C.

"Avoid applying lotion to your baby's skin."

D.

"Keep a hat on your baby during treatment."

E.

"We will give your baby glucose water between breast feedings.

F.

"Bilirubin is primarily excreted through the stool."

G.

The treatment lights can cause a transient skin rash on your baby."

H.

The treatment lights emit a significant amount of ultraviolet radiation.

Answer and Explanation

The Correct Answer is {"A":{"answers":"A"},"B":{"answers":"A"},"C":{"answers":"A"},"D":{"answers":"B"},"E":{"answers":"B"},"F":{"answers":"A"},"G":{"answers":"A"},"H":{"answers":"B"}}

Statement

Include

Not Include

"Your baby needs to be repositioned every 2 to 3 hours while under the lights."

✅

 

"Your baby's eyes will be covered with an eye shield during therapy."

✅

 

"Avoid applying lotion to your baby's skin."

✅

 

"Keep a hat on your baby during treatment."

 

✅

"We will give your baby glucose water between breast feedings.

 

✅

"Bilirubin is primarily excreted through the stool."

✅

 

The treatment lights can cause a transient skin rash on your baby."

✅

 

The treatment lights emit a significant amount of ultraviolet radiation.

 

✅

 

  • Repositioning every 2 to 3 hours exposes different skin areas to light, enhancing bilirubin breakdown and preventing pressure sores.
  • Eye shields protect the newborn’s eyes from damage caused by bright phototherapy lights.
  • Avoiding lotion prevents skin irritation or burns and ensures effective light penetration during treatment.
  • Keeping a hat on blocks light exposure to the scalp, reducing the effectiveness of phototherapy.
  • Glucose water is not recommended; feeding with breast milk or formula helps promote bilirubin elimination through stools.
  • Bilirubin is mainly excreted through the stool after being converted into a water-soluble form by phototherapy.
  • Phototherapy can cause a mild, temporary rash, which is harmless but important to inform parents about.
  • Phototherapy lights emit blue light, not harmful ultraviolet radiation, making them safe for newborn treatment.


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Related Questions

Correct Answer is {"A":{"answers":"C"},"B":{"answers":"A,B,C"},"C":{"answers":"B"},"D":{"answers":"A,B,C"}}

Explanation

  • Vitamin B12 level: A B12 level of 159 pg/mL is below normal and consistent with pernicious anemia. This condition is caused by a lack of intrinsic factor, impairing B12 absorption in the gut. The client’s vegan diet may further reduce B12 intake, worsening deficiency.
  • Fatigue: Fatigue results from decreased oxygen delivery to tissues due to low hemoglobin in all anemias. In sickle cell disease, abnormally shaped RBCs impair perfusion. Iron and B12 deficiencies impair RBC production, further contributing to fatigue.
  • Ferritin level: Ferritin reflects the body’s iron storage, and a level of 8 ng/mL is below the normal range. Low ferritin confirms iron depletion, a hallmark of iron deficiency anemia. This can result from dietary lack or chronic inflammation, like in rheumatoid arthritis.
  • Orthostatic hypotension: Orthostatic hypotension may occur with all anemias due to reduced circulating volume and poor oxygenation. Low hemoglobin and hematocrit lead to impaired vascular tone and autonomic response, causing dizziness or lightheadedness when standing.

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

Explanation

A. Abdominal assessment – The abdomen is tender to palpation, which is an abnormal finding and can indicate uterine activity or irritation associated with preterm labor or other complications.
B. Low back pain – This is a common early sign of preterm labor, especially when combined with uterine cramping and cervical changes.
C. Uterine contractions – Although the client has cramping, there is no specific documentation of palpable or monitor-confirmed contractions, so this cannot be definitively selected based on available data.
D. Abdominal cramping – This is concerning in a pregnant client at 30 weeks, especially in combination with cervical dilation, vaginal bleeding, and back pain.
E. Fundal height – At 30 weeks, a fundal height of 28 cm is within the normal range (should match gestational age ±2 cm). This is not abnormal.
F. Fetal heart rate – The scenario notes positive fetal movement but does not mention an abnormal FHR. Without abnormal FHR data, this cannot be selected.

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