A nurse is caring for an infant who is receiving phototherapy. Which of the following findings requires intervention by the nurse?

The mother applies lotion to the newborn's skin.

The newborn's stools increase in number.

A pink rash appears on the newborn's trunk.

The newborn's eyes are covered with a mask.

Answer and Explanation

The Correct Answer is A

Choice A reason: The mother applying lotion to the newborn's skin requires intervention by the nurse, because it can interfere with the effectiveness of phototherapy and increase the risk of thermal injury. The nurse should instruct the mother to avoid using any lotions, creams, or oils on the newborn's skin during phototherapy.

Choice B reason: The newborn's stools increasing in number does not require intervention by the nurse, because it is a normal and expected outcome of phototherapy. Phototherapy can increase the breakdown and excretion of bilirubin, which can result in more frequent and loose stools.

Choice C reason: A pink rash appearing on the newborn's trunk does not require intervention by the nurse, because it is a common and harmless side effect of phototherapy. The rash usually disappears within a few days after phototherapy is discontinued.

Choice D reason: The newborn's eyes being covered with a mask does not require intervention by the nurse, because it is a standard and essential precaution for phototherapy. The mask protects the newborn's eyes from the harmful effects of the light, such as corneal damage or retinal injury.

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Correct Answer is B

Explanation

Choice A reason: Blunt force trauma is a possible risk factor for placental abruption, which is a condition where the placenta detaches from the uterine wall and causes bleeding, pain, and fetal distress. However, blunt force trauma is not the most common risk factor, as it accounts for only a small percentage of cases. The most common causes of blunt force trauma are motor vehicle accidents, falls, or domestic violence.

Choice B reason: Hypertension is the most common risk factor for placental abruption, as it affects about 50% of cases. Hypertension can cause vasospasm and reduced blood flow to the placenta, which can weaken the attachment and lead to separation. Hypertension can be chronic, gestational, or related to preeclampsia.

Choice C reason: Gestational diabetes mellitus is not a risk factor for placental abruption, but rather a condition where the client develops high blood sugar levels during pregnancy and can cause complications, such as macrosomia, polyhydramnios, or neonatal hypoglycemia. Gestational diabetes mellitus does not affect the placental attachment or function.

Choice D reason: Cigarette smoking is a risk factor for placental abruption, as it can cause vasoconstriction and reduced oxygen delivery to the placenta, which can impair its growth and development. However, cigarette smoking is not the most common risk factor, as it affects about 25% of cases.

A. Asymmetric thigh folds B. Absent plantar reflexes C. Lengthened thigh on the affected side D. Inwardly turned foot on the affected side

Correct Answer is A

Explanation

Choice A reason: Asymmetric thigh folds is a common finding in newborns who have DDH, because the affected hip is dislocated or subluxated, causing the thigh to appear shorter and the skin folds to be uneven. The nurse should compare the number and depth of the skin folds on both sides of the groin and buttocks.

Choice B reason: Absent plantar reflexes is not a typical finding in newborns who have DDH, because it is not related to the hip joint. The plantar reflex is a normal reflex that causes the toes to curl when the sole of the foot is stroked. The nurse should assess the plantar reflex in all newborns, regardless of their hip status.

Choice C reason: Lengthened thigh on the affected side is not a usual finding in newborns who have DDH, because the opposite is true. The affected thigh is usually shorter than the unaffected thigh, due to the displacement of the femoral head from the acetabulum. The nurse should measure the length of both thighs from the anterior superior iliac spine to the medial malleolus.

Choice D reason: Inwardly turned foot on the affected side is not a specific finding in newborns who have DDH, because it can be caused by other conditions, such as metatarsus adductus or clubfoot. The inward turning of the foot is not a direct result of the hip disorder, but rather a secondary effect of the abnormal positioning of the leg. The nurse should examine the alignment and mobility of the foot and ankle.

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A nurse is caring for an infant who is receiving phototherapy. Which of the following findings requires intervention by the nurse?

Nursing Test Bank

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