A nurse is caring for a newborn who has hyperbilirubinemia and is receiving phototherapy.
Which of the following interventions should the nurse implement?
Apply sunscreen to the newborn’s skin before placing under the lights.
Cover the newborn’s eyes with eye shields or patches.
Turn off the phototherapy lights during feedings.
Keep the newborn fully clothed to prevent heat loss.
The Correct Answer is B
Cover the newborn’s eyes with eye shields or patches. This is because phototherapy can cause eye damage and irritation to the newborn, so the eyes should be protected while the lights are on.
Some possible explanations for the other choices are:
• Choice A is wrong because applying sunscreen to the newborn’s skin before placing under the lights can interfere with the effectiveness of phototherapy and increase the risk of skin irritation and infection.
• Choice C is wrong because turning off the phototherapy lights during feedings can reduce the exposure time and delay the clearance of bilirubin from the newborn’s blood.
• Choice D is wrong because keeping the newborn fully clothed to prevent heat loss can also interfere with the effectiveness of phototherapy and increase the risk of overheating and dehydration.
Normal ranges for bilirubin levels in newborns vary depending on the age, gestational age, and risk factors of the newborn. Generally, a total serum bilirubin level of less than 12 mg/dL (205 micromol/L) is considered normal for term newborns in the first week of life. Phototherapy is usually indicated when the total serum bilirubin level exceeds 15 mg/dL (257 micromol/L) for term newborns or 10 mg/dL (171 micromol/L) for preterm newborns.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
The newborn had some problems at birth but is now in excellent condition.
The Apgar score is a method of assessing the health of a newborn on a scale of 0 to 10 based on five criteria: appearance, pulse, grimace, activity, and respiration.
A score of 7 to 10 indicates that the newborn is in good condition and does not need any special care.
A score of 4 to 6 indicates that the newborn has some problems and may need some assistance.
A score of 0 to 3 indicates that the newborn is in serious trouble and needs immediate medical attention.
Choice A is wrong because a score of 8 at one minute after birth does not indicate a difficult transition.
It means that the newborn had only minor problems and was in good condition.
Choice B is wrong because a score of 10 at five minutes after birth does not indicate an improvement from a score of 8.
It means that the newborn had no problems and was in excellent condition.
Choice D is wrong because a score of 10 at five minutes after birth does not indicate a deterioration from a score of 8.
It means that the newborn had no problems and was in excellent condition.
Normal ranges for the Apgar score are:
• At one minute after birth: 7 to 10
• At five minutes after birth: 8 to 10
Correct Answer is D
Explanation
Based on the Apgar score components provided, the newborn would likely receive the following scores:
- Appearance (color):Pink all over -2 points
- Pulse (heart rate):120 bpm -2 points
- Grimace (reflex irritability):Makes a strong cry -2 points
- Activity (muscle tone):Active movement -2 points
- Respiration:Deep, regular breaths -2 points
Adding these together, the newborn’s Apgar score would be10, which indicates the baby is in excellent condition following delivery.
The Apgar score is a quick assessment method used to evaluate a newborn baby’s health immediately after birth and again 5 minutes later. It was created by Dr. Virginia Apgar in 1952 and is an important tool for healthcare professionals to determine the immediate physical condition of a newborn and the need for any urgent medical care.
Here’s what the Apgar score measures, with each category receiving a score from 0 to 2:
- Appearance (color):Checks the baby’s skin tone
- Pulse (heart rate):Measures the heart rate
- Grimace (reflex irritability):Assesses the reflex response
- Activity (muscle tone):Evaluates muscle tone and movement
- Respiration:Observes the breathing effort and regularity
The significance of the Apgar score lies in its ability to provide a standardized and rapid assessment of a newborn’s vital signs and immediate health. It helps to quickly identify babies who are struggling and may need additional medical attention.However, it’s important to note that the Apgar score is not designed to predict long-term health outcomes or neurological development.It’s one of many assessments used to understand a baby’s condition at birth.
Here’s a table that outlines the Apgar score criteria and the points assigned for each:
Table
|
Criteria |
0 Points |
1 Point |
2 Points |
|
Appearance (Color) |
Blue or pale all over |
Body pink, extremities blue |
Pink all over |
|
Pulse (Heart Rate) |
Absent |
Less than 100 bpm |
100 bpm or more |
|
Grimace Response |
No response to stimulation |
Grimace or weak cry |
Strong cry, pulls away |
|
Activity (Muscle Tone) |
Limp |
Some flexion of extremities |
Active motion |
|
Respiration |
Absent |
Slow or irregular breathing |
Good, strong cry |
The Apgar score is calculated at 1 minute and 5 minutes after birth. Each of the five criteria is scored between 0 and 2, with a maximum total score of 10. This scoring system helps medical professionals quickly assess the newborn’s general condition and determine if any immediate medical intervention is needed. A score of 7 to 10 is considered normal, 4 to 6 fairly low, and 3 and below critically low.
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