A nurse is caring for a newborn with hyperbilirubinemia and is being treated with phototherapy.
For each of the following nursing actions, specify if it is indicated or contraindicated with phototherapy treatment.
Apply lotion to the skin every 4 hours.
Remove the newborn from phototherapy every 4 hours for thorough assessment of adverse effects of phototherapy.
Newborn feedings should be every 8 hours.
Maintain an eye mask over the newborn's eyes.
Reposition the newborn every 2 hours.
Report sunken fontanels to the provider.
The Correct Answer is {"A":{"answers":"B"},"B":{"answers":"A"},"C":{"answers":"B"},"D":{"answers":"A"},"E":{"answers":"A"},"F":{"answers":"A"}}
Indicated:
B. Remove the newborn from phototherapy every 4 hours for thorough assessment of adverse effects of phototherapy.
D. Maintain an eye mask over the newborn's eyes.
E. Reposition the newborn every 2 hours.
F. Report sunken fontanels to the provider.
Contraindicated:
A. Apply lotion to the skin every 4 hours.
C. Newborn feedings should be every 8 hours.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale
Pelvic pain and fatigue can be indicators of endometritis, an infection of the uterine lining. It often manifests with pain, fever, and general malaise, and requires further evaluation and intervention.
Choice B rationale
Light amount of dark red lochia with a bloody odor is a normal postpartum finding. Lochia progresses through different stages, and dark red lochia, which occurs in the later stages, typically has a bloody odor.
Choice C rationale
Hematuria, or the presence of blood in the urine, is not a typical symptom of endometritis. It may indicate a urinary tract infection or other renal issues instead.
Choice D rationale
A localized area of breast tenderness may indicate mastitis, an infection of the breast tissue. It is not related to endometritis but requires attention and treatment.
Correct Answer is {"A":{"answers":"B"},"B":{"answers":"A"},"C":{"answers":"B"},"D":{"answers":"A"},"E":{"answers":"A"},"F":{"answers":"A"}}
Explanation
Indicated:
B. Remove the newborn from phototherapy every 4 hours for thorough assessment of adverse effects of phototherapy.
D. Maintain an eye mask over the newborn's eyes.
E. Reposition the newborn every 2 hours.
F. Report sunken fontanels to the provider.
Contraindicated:
A. Apply lotion to the skin every 4 hours.
C. Newborn feedings should be every 8 hours.
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