A nurse is caring for a newborn who has a prescription for phototherapy. Which of the following actions should the nurse take?
Apply lotion to the newborn's skin every 4 hr.
Keep the newborn's head covered with a cap.
Supplement the newborn with glucose water between feedings.
Reposition the newborn every 2 hr.
The Correct Answer is D
A. Apply lotion to the newborn's skin every 4 hr: Lotions or ointments should be avoided during phototherapy because they can interact with the light and increase the risk of skin irritation or burns. The newborn’s skin should be kept clean and dry.
B. Keep the newborn's head covered with a cap: Covering the head is unnecessary and may interfere with heat dissipation. Phototherapy aims to expose as much skin as possible while protecting the eyes with an eye shield.
C. Supplement the newborn with glucose water between feedings: Glucose water is not recommended. Frequent breastfeeding or formula feeding supports hydration and promotes bilirubin excretion more effectively than glucose water.
D. Reposition the newborn every 2 hr: Frequent repositioning helps expose different areas of skin to the phototherapy light, promoting even breakdown of bilirubin and preventing pressure injuries. It is an essential part of nursing care during phototherapy.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. "Explain what you were doing to get hit." This statement implies blame or justification for the abuse and can cause the child to feel guilt or shame, which is inappropriate and non-therapeutic.
B. "Why do you think that you are being abused?" This question may sound accusatory or suggest that the child is responsible for the abuse. It can discourage open communication and retraumatize the child.
C. "I am sure everything will work out just fine." This is a false reassurance. It dismisses the child’s emotions and does not validate their experience, which can hinder trust-building.
D. "Can you tell me how you are feeling?" This open-ended, nonjudgmental question encourages the child to express emotions and builds therapeutic rapport. It provides emotional support in a safe, respectful manner.
Correct Answer is C
Explanation
A. Notify the ethics committee of the breach of confidentiality: Involving the ethics committee is typically reserved for complex ethical dilemmas. A first-line breach like this can be addressed directly through education and supervisory action before escalation.
B. File incident report with the risk management department: While incident reporting may be appropriate in severe or repeated breaches, an informal but direct correction is more suitable for a first-time or minor violation observed in real time.
C. Remind the AP about maintaining client confidentiality: The nurse should address the situation immediately by reminding the APs of their obligation to uphold HIPAA regulations. This direct intervention helps prevent further breaches and reinforces professional standards.
D. Notify the client of the breach of confidentiality: Informing the client of the breach is not the nurse’s initial responsibility in this context. That step is generally handled through administrative processes if the breach significantly affects the client.
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