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.
The Correct Answer is A
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Related Questions
Correct Answer is C
Explanation
The correct answer is C. Place the client in a lateral position.
A. Elevating the client's legs is not the priority in this situation. Placing the client in a lateral position is more appropriate to improve blood flow and prevent supine hypotension.
B. Notifying the provider is an important action but not the immediate priority. Addressing the client's position and blood pressure is crucial before contacting the provider.
C. Placing the client in a lateral position is the priority nursing action.
The low blood pressure may be due to aortocaval compression (supine hypotension) caused by the weight of the uterus on the vena cava. Turning the client onto her side alleviates this compression and helps improve blood flow.
D. Monitoring vital signs every 5 minutes is important, but the immediate action should be to address the client's position and blood pressure. Continuous monitoring and further interventions can follow.
Correct Answer is B
Explanation
The correct answer is B. Explain to the client this is an expected occurrence.
A. Tell the client to follow up with a dermatologist: While it's always good to encourage clients to seek professional advice if they have concerns, in the context of melasma during pregnancy, it is generally a normal physiological change. A dermatologist may not be needed specifically for this condition unless there are other unusual symptoms.
B. Explain to the client this is an expected occurrence: This is the correct action. It's important for the nurse to reassure the client that blotchy hyperpigmentation on the forehead is a common and expected change during pregnancy. Providing education and support can help alleviate the client's concerns.
C. Instruct the client to increase her intake of vitamin D: Blotchy hyperpigmentation is not typically addressed by increasing vitamin D intake. While adequate nutrition is important during pregnancy, this specific concern is related more to hormonal changes than nutritional deficiencies.
D. Inform the client she might have an allergy to her skin care products: Melasma is primarily related to hormonal changes in pregnancy rather than an allergic reaction to skin care products. While assessing for allergies is essential in certain situations, it may not be the primary concern in this case.
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