A nurse is caring for a newborn who has an order for phototherapy to treat hyperbilirubinemia. Which of the following actions should the nurse take?

Place eye covers on the newborn while under the lights.

Apply an emollient lotion to skin that is exposed to the lights.

Remove all blankets, clothing and diapers while the newborn is under lights

Keep the newborn as close to the light source as possible.

Answer and Explanation

The Correct Answer is A

Rationale:

A. Place eye covers on the newborn while under the lights: Eye protection is essential during phototherapy to prevent retinal damage from the high-intensity blue light. The covers should be properly fitted and removed only during feedings or when the therapy is paused.

B. Apply an emollient lotion to skin that is exposed to the lights: Emollients are not recommended during phototherapy because they can increase the risk of burns or interfere with light penetration. The newborn’s skin should remain clean and dry to ensure safety and effective treatment.

C. Remove all blankets, clothing and diapers while the newborn is under lights: While minimal clothing is used to expose as much skin as possible, the diaper is typically kept in place to protect the genital area and reduce the risk of contamination. Full removal is not necessary or recommended.

D. Keep the newborn as close to the light source as possible: The distance between the newborn and the phototherapy light should be within manufacturer guidelines. Moving the newborn too close can increase the risk of overheating or skin damage, so positioning must follow safety standards.

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Correct Answer is A

Explanation

Rationale:

A. "The client can revoke consent even after the procedure has begun.": Clients have the legal right to withdraw consent at any time, including during a procedure. Respecting this autonomy is essential, and healthcare providers must stop the procedure if the client revokes consent.

B. "The nurse is responsible for obtaining informed consent.": Obtaining informed consent is the responsibility of the provider performing the procedure, who must ensure the client understands the risks, benefits, and alternatives. Nurses typically witness and verify the signature but do not obtain consent.

C. "Consent must be obtained from a family member if a client has a mental illness.": Consent depends on the client’s decision-making capacity, not solely on the presence of mental illness. If the client is competent, they can provide consent; if not, a legally authorized representative may be involved.

D. "The charge nurse will explain the risks of the procedure to the client.": Explaining procedure risks is the responsibility of the healthcare provider performing the procedure, not the charge nurse. This ensures that the explanation is accurate and comprehensive.

A. Swelling of the lips B. Nauses C. Hand tremors D. Hyperglycemia

Correct Answer is A

Explanation

Rationale:

A. Swelling of the lips: Swelling of the lips can be an early sign of anaphylaxis, a severe allergic reaction. Epinephrine is the first-line treatment for anaphylaxis because it rapidly reduces airway swelling, improves breathing, and supports blood pressure by constricting blood vessels.

B. Nausea: While nausea may occur during an allergic reaction, it is not a primary life-threatening symptom addressed by epinephrine. Epinephrine targets cardiovascular and respiratory symptoms more directly, not gastrointestinal discomfort.

C. Hand tremors: Tremors are actually a potential side effect of epinephrine due to its stimulation of the sympathetic nervous system. The medication is not intended to treat tremors and may even cause or worsen them temporarily.

D. Hyperglycemia: Epinephrine can increase blood glucose levels as a side effect, but it is not prescribed to treat or manage hyperglycemia. Managing blood glucose is not part of the therapeutic purpose of this emergency medication.

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A nurse is caring for a newborn who has an order for phototherapy to treat hyperbilirubinemia. Which of the following actions should the nurse take?

Nursing Test Bank

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