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.

Answer and Explanation

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.

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Correct Answer is A

Explanation

Carbon monoxide poisoning.

This is because the client reports having a headache and vertigo after turning on his furnace for the first time this season.These are common symptoms of carbon monoxide poisoning, which can occur when carbon monoxide, a colorless and odorless gas, builds up in the blood due to exposure to combustion fumes.

The furnace may have been a source of carbon monoxide if it was not well vented or maintained.

The other statements are wrong because:

Meniere’s disease is a disorder of the inner ear that causes vertigo, hearing loss, tinnitus and ear fullness. It is not related to carbon monoxide exposure or furnace use.

Migraine is a type of headache that causes throbbing pain, nausea, sensitivity to light and sound, and sometimes visual disturbances. It is not caused by carbon monoxide exposure or furnace use, but by genetic and environmental factors.

Benign paroxysmal positional vertigo (BPPV) is a condition that causes brief episodes of vertigo triggered by changes in head position. It is caused by tiny crystals in the inner ear that become dislodged and stimulate the balance sensors. It is not related to carbon monoxide exposure or furnace use.

A. Sunken fontanelles B. Bulging fontanelles C. Diamond-shaped anterior fontanelle D. Triangular posterior fontanelle.

Correct Answer is B

Explanation

Bulging fontanelles.Bulging fontanelles can be a sign of increased intracranial pressure or intracranial and extracranial tumors.This is a potential problem for the newborn’s brain and health and should be evaluated by imaging studies.

Choice A is wrong because sunken fontanelles are usually a sign of dehydration, which is not a problem with the fontanelles themselves, but with the fluid balance of the newborn.

Choice C is wrong because a diamond-shaped anterior fontanelle is normal for a newborn.The anterior fontanelle is the largest and most important for clinical evaluation.It has an average size of 2.1 cm and a median time of closure of 13.8 months.

Choice D is wrong because a triangular posterior fontanelle is also normal for a newborn.The posterior fontanelle is smaller than the anterior one and normally closes by 8 weeks.

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A nurse is caring for a newborn who has hyperbilirubinemia and is receiving phototherapy. Which of the following interventions should the nurse implement?

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Naxlex Comprehensive Predictor Exams

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Correct Answer is A

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A nurse is caring for a newborn who has hyperbilirubinemia and is receiving phototherapy.

Which of the following interventions should the nurse implement?