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.

Answer and Explanation

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.

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Correct Answer is ["A"]

Explanation

Choice A reason: The correct answer is choice A. The nurse should expect the presence of the Moro reflex in a 6-month-old infant. The Moro reflex is a normal primitive reflex seen in infants up to about 6 months of age. When the infant experiences a sudden loss of support or a loud noise, they react by extending their arms and legs and then pulling them back in, as if trying to grasp onto something. This reflex is an important indicator of the baby's neurological development.

Choice B reason:

The birth weight doubling by 6 months of age is a typical growth milestone for infants. However, this statement is not correct in the context of the question, as it is not something the nurse should "expect” during a well-child visit. Instead, it is a general developmental milestone that healthcare providers monitor over time.

Choice C reason:

The correct answer is choice C. The nurse should expect the posterior fontanel to be closed in a 6-month-old infant. Fontanels are soft spots on a baby's skull that allow for brain growth during early development. The posterior fontanel, located at the back of the head, is typically closed by 6 months of age.

Choice D reason:

The correct answer is choice D. At 6 months of age, many infants can sit unsupported. However, not all infants achieve this milestone at the exact same age. Some may achieve it a bit earlier, while others might take a little more time. It is essential for the nurse to assess the infant's developmental progress and provide appropriate guidance to the parents.

Choice E:

The correct answer is choice E. By 6 months of age, some infants may be able to move from their back to their front. This is usually accomplished through rolling over. However, like other developmental milestones, the age at which infants achieve this can vary. Therefore, while the nurse may expect this ability in some infants, it is not something that all 6-month- old infants will have mastered at the time of the well-child visit.

A. Ask the client to empty their bladder. B. Assist the client into a left-lateral position. C. Apply an external fetal monitor to the clients abdomen. D. Instruct the client to perform nipple stimulation. E. Able to move from back to front.

Correct Answer is ["A","B","C"]

Explanation

Choice A reason: The nurse should plan to ask the client to empty their bladder before performing Leopold maneuvers. The rationale behind this is to ensure that the client's bladder is empty to allow for better palpation of the uterus and fetal position. A full bladder can interfere with accurate assessment and may lead to incorrect findings during the examination.

Choice B reason:

The nurse should assist the client into a left-lateral position. This position is ideal for performing Leopold maneuvers because it helps to displace the uterus away from the vena cava, reducing the risk of supine hypotension syndrome. Moreover, the left-lateral position promotes optimal blood flow to the placenta, which is essential for the well-being of the fetus during the examination.

Choice C reason:

The nurse should apply an external fetal monitor to the client's abdomen after completing the Leopold maneuvers. The purpose of Leopold maneuvers is to determine the fetal position and presentation manually. Once this information is obtained, applying the external fetal monitor allows continuous monitoring of the fetal heart rate and uterine contractions to assess the baby's well-being and the progression of labor.

Choice D reason:

The nurse should not instruct the client to perform nipple stimulation when planning to assist with Leopold maneuvers. Nipple stimulation is a method to induce or augment labor, and it is not related to the process of assessing fetal position and presentation using Leopold maneuvers. It may lead to unnecessary contractions and confusion during the examination.

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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?

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