A nurse is contributing to the plan of care for a newborn who requires phototherapy for hyperbilirubinemia. Which of the following interventions should the nurse recommend including in the plan?

Apply a water-based ointment to the newborn's skin every 4 to 6 hr.

Give the newborn 30 mL of distilled water after each feeding

Reposition the newborn every 2 to 3 hr.

Monitor the newborn's blood glucose level every 2 hr

Answer and Explanation

The Correct Answer is C

A)   Incorrect- Applying ointment to the skin during phototherapy is typically avoided as it can interfere with the effectiveness of the therapy.
B)   Incorrect- Giving distilled water after feedings is not a typical intervention for phototherapy.
C)   Correct - Repositioning the newborn every 2 to 3 hours is important to ensure adequate exposure of the skin to the phototherapy lights and to prevent pressure points.
D)   Incorrect- Monitoring blood glucose levels is not a standard intervention during phototherapy unless there are specific indications for doing so.

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Correct Answer is A

Explanation

A) Correct - A hemoglobin level of 9.5 g/dL in a full-term newborn is lower than the expected range and should be reported to the provider for further evaluation.
B) Incorrect- Platelets of 225,000/mm3 are within the normal range for newborns and do not require immediate reporting.
C) Incorrect- A glucose level of 60 mg/dL is within the normal range for a newborn and does not require immediate reporting.
D) Incorrect- A white blood cell count of 10,000/mm3 is within the normal range for a newborn and does not require immediate reporting.

A. Elevated blood pressure B. Leukopenia C. Hydramnios D. Ketonuria

Correct Answer is C

Explanation

A) Incorrect- Elevated blood pressure is not a primary risk associated with hyperemesis gravidarum.
B) Incorrect- Leukopenia (low white blood cell count) is not a common consequence of hyperemesis gravidarum.
C) Correct - Hyperemesis gravidarum, severe nausea, and vomiting during pregnancy can lead to dehydration, which may affect amniotic fluid levels and result in hydramnios (excessive amniotic fluid).
D) Incorrect- Ketonuria (presence of ketones in the urine) is a possible consequence of excessive vomiting, but it's not the primary concern associated with hyperemesis gravidarum.

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A nurse is contributing to the plan of care for a newborn who requires phototherapy for hyperbilirubinemia. Which of the following interventions should the nurse recommend including in the plan?

Nursing Test Bank

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