A nurse is contributing to the plan of care for a newborn who has hyperbilirubinemia and requires phototherapy. Which of the following interventions should the nurse include?
Apply lotion to the newborn's skin twice per day.
Check the newborn's blood glucose every 2 hr.
Swaddle the newborn during the treatment.
Remove the newborn's eye mask during feedings.
The Correct Answer is D
Swaddle the newborn during the treatment. Choice A reason:
Apply lotion to the newborn's skin twice per day. Rationale: The nurse should not apply lotion to the newborn's skin during phototherapy. Phototherapy involves exposing the baby's skin to light to treat hyperbilirubinemia. Applying lotion may interfere with the effectiveness of the treatment or cause adverse reactions.
Choice B reason:
Check the newborn's blood glucose every 2 hours. Rationale: While monitoring the newborn's blood glucose is an essential part of neonatal care, it is not directly related to phototherapy or the treatment of hyperbilirubinemia. Glucose monitoring is typically done to assess for hypoglycemia or other metabolic disturbances.
Choice C reason:
Swaddle the newborn during the treatment. Rationale: The newborn should not be swaddled during phototherapy because it limits exposure of the skin to the phototherapy lights, which is essential for reducing bilirubin levels.
Choice D reason:
Remove the newborn's eye mask during feedings. Rationale:The eye mask is used to protect the newborn's eyes from the bright lights during phototherapy, but it can be removed for feeding. It’s important to ensure that the newborn is fed properly, so removing the mask during feeding is a reasonable and necessary intervention.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A reason:
The Visual Analog Scale (VAS) is a pain rating scale that involves a straight line with one end representing "no pain” and the other end representing "worst pain imaginable.” The individual marks a point on the line to indicate their pain level. This scale may not be suitable for a 3-year-old child as it requires a certain level of cognitive and numerical understanding to make a meaningful assessment, which a young child may not possess.
Choice B reason:
The FACES pain rating scale is a visual tool that uses a series of facial expressions ranging from smiling to crying to help individuals, especially children, express their pain level. A 3-year-old child can easily point to the facial expression that best matches their pain experience, making it a suitable choice for this age group.
Choice C reason:
The Word-Graphic Scale is a pain rating scale that combines verbal descriptors with a visual representation of the pain intensity. It may include words like "no pain,” "mild pain,” "moderate pain,” and "severe pain” along with corresponding symbols. While it can be used with children, a 3-year-old might have difficulty grasping the abstract nature of the scale and correlating words with pain levels.
Choice D reason:
The Numeric Rating Scale (NRS) requires the individual to rate their pain level on a scale from 0 to 10, with 0 being "no pain” and 10 being "worst pain.” Similar to the Visual Analog Scale, this scale might not be suitable for a 3-year-old child who may not fully understand abstract numerical concepts.
Correct Answer is D
Explanation
Choice D reason: The nurse should report the laboratory result of 2+ proteinuria (Choice D) to the healthcare provider. Proteinuria is the presence of excess protein in the urine, which can indicate a potential kidney problem or a complication related to pregnancy, such as preeclampsia. Preeclampsia is a serious condition characterized by high blood pressure and damage to organs like the liver and kidneys. Therefore, this result needs immediate attention to assess the client's condition properly and take appropriate actions to ensure the safety and well-being of both the mother and the baby.
Choice A reason:
The 2-hour postprandial glucose level of 105 mg/dL (Choice A) is within the normal range. During pregnancy, glucose levels are carefully monitored to check for gestational diabetes. In this case, the result falls within the acceptable range, indicating that the client's glucose levels are stable, and gestational diabetes is not a concern at this time.
Choice B reason:
A negative group B streptococcus (GBS) B-hemolytic result (Choice B) is actually a positive finding. It means that the client does not have an active infection with group B streptococcus, which is essential information for the management of labor and delivery. Therefore, there is no need to report this result to the provider as it indicates a favorable condition.
Choice C reason:
The hemoglobin (Hgb) level of 13 g/dL (Choice C) is within the normal range for a non- pregnant adult female. During pregnancy, blood volume increases, and hemoglobin levels can naturally decrease. However, the provided value is still within the acceptable range, indicating that the client's blood oxygen-carrying capacity is adequate and there is no immediate concern.
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