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

Cover the newborn's eyes while under the phototherapy light: It is important to protect the newborn's eyes from the bright light during phototherapy. Covering the eyes with an eye mask or using a specific eye shield helps prevent potential eye damage.

Keep the newborn in a shirt while under the phototherapy light: The newborn should ideally be undressed and have as much skin exposed to the phototherapy light as possible. This enhances the effectiveness of the treatment by allowing more skin surface to be exposed to the light.

Apply a light moisturizing lotion to the newborn's skin: It is generally recommended to avoid applying lotions or oils to the newborn's skin during phototherapy, as these substances can interfere with the effectiveness of the treatment. The skin should be clean and dry.

Turn and reposition the newborn every 4 hr while undergoing phototherapy: Turning and repositioning the newborn is important for general care, but the frequency may be more frequent than every 4 hours, especially when undergoing phototherapy. The goal is to ensure even exposure of the skin to the light.

Answer and Explanation

The Correct Answer is A

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Correct Answer is B

Explanation

A. Contractions that last 45 seconds each with a 3-minute rest between contractions are less common. Typically, contractions last around 60 seconds during active labor.

B. Contractions that last for 60 seconds each with a 3-min rest between contractions is the expected pattern.

During active labor, contractions are commonly around 60 seconds in duration, and they occur approximately every 4-5 minutes.

C. Contractions that last for 60 seconds each with a 4-min rest between contractions are not consistent with the usual pattern of contractions in active labor. A 4-minute rest between contractions would be an extended interval.

D. A contraction that lasts for 4 minutes followed by a period of relaxation is not typical and may indicate a problem. Normal contractions usually last around 60 seconds or less.

A. Contractions lasting longer than 90 seconds B. Contractions occurring every 3 to 5 min C. Client reports feeling contractions in lower back D. Contractions are strong in intensity

Correct Answer is A

Explanation

The correct answer is A. Contractions lasting longer than 90 seconds.

A. Contractions lasting longer than 90 seconds can be indicative of a prolonged contraction, which may affect uteroplacental perfusion and fetal oxygenation. This is a concern and should be reported to the provider.

B. Contractions occurring every 3 to 5 minutes are within the normal frequency range during the active phase of the first stage of labor.

C. The client reporting feeling contractions in the lower back is a common description of back labor, which may occur due to the position of the baby. It is not necessarily a cause for immediate concern unless it is associated with other issues.

D. Contractions being strong in intensity is expected during the active phase of labor. Strong contractions are necessary for cervical dilation and the progression of labor.

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

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Naxlex Comprehensive Predictor Exams

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Correct Answer is B

Explanation

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Correct Answer is A

Explanation

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