A nurse is caring for an infant who has spina bifida.
Which of the following actions should the nurse take?

Choice A rationale

Performing the most invasive assessment first can cause distress and fear in a preschooler. It’s generally recommended to start with less invasive procedures to build trust and cooperation.

Choice B rationale

Separating a child from their caregiver during an examination can cause anxiety and fear. It’s often beneficial to have the caregiver present during the examination to provide comfort and reassurance.

Choice C rationale

Allowing a child to role-play using miniature equipment can help alleviate fears and anxieties about the examination. It gives the child a sense of control and understanding of what to expect.

Choice D rationale

While it’s important to explain procedures to a child, using medical terminology can confuse and scare them. It’s better to use simple, age-appropriate language that the child can understand.

Choice A rationale

Applying lotion to the newborn’s skin twice per day is not necessary during phototherapy. The main goal of phototherapy is to reduce the level of bilirubin in the newborn’s blood. Applying lotion can interfere with the effectiveness of the light therapy and can cause the newborn’s skin to overheat.

Choice B rationale

Monitoring the newborn’s blood glucose level hourly is not necessary during phototherapy unless the newborn has a specific condition that requires close monitoring of blood glucose levels. Phototherapy does not directly affect blood glucose levels.

Choice C rationale

Encouraging the newborn to breastfeed every 2 hours is an important part of the care plan for a newborn undergoing phototherapy. Frequent feeding can help to promote the excretion of bilirubin through the newborn’s stool.

Choice D rationale

Maintaining the newborn in a prone position is not necessary during phototherapy. The newborn should be placed in a variety of positions to ensure that all areas of the skin are exposed to the light.