A nurse is planning care for a full-term newborn who is receiving phototherapy. Which of the following actions should the nurse include in the plan of care?
Avoid using lotion or ointment on the newborn's skin.
Dress the newborn in lightweight clothing.
Keep the newborn supine throughout treatment.
Measure the newborn's temperature every 6 hr.
The Correct Answer is A
Choice A rationale:
When a newborn is receiving phototherapy for hyperbilirubinemia, it is essential to avoid using lotions or ointments on the skin. Phototherapy works by breaking down bilirubin in the skin, and any barriers like lotions or ointments can interfere with this process. The baby's skin needs to be exposed to the light to effectively reduce bilirubin levels.
Choice B rationale:
Dressing the newborn in lightweight clothing is a correct action during phototherapy. The baby should be undressed and placed under the phototherapy lights, with only a diaper on to maximize skin exposure to the light.
Choice C rationale:
Keeping the newborn supine throughout treatment is not a recommended action during phototherapy. To optimize skin exposure to the light, the baby should be placed in a prone position, with the back exposed to the light source.
Choice D rationale:
Measuring the newborn's temperature every 6 hours is essential, but it is not directly related to phototherapy. Temperature monitoring is a routine part of newborn care to assess for signs of infection or other health issues.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A rationale:
To calculate the estimated date of delivery using Nägele's Rule, subtract three months from the first day of the last menstrual period (August 10), and then add seven days. However, choice A (May 20) is incorrect because it adds eight days instead of seven.
Choice B rationale:
It does not add seven days to the calculation.
Choice C rationale:
It adds three days instead of seven to the calculation
Choice D rationale:
It follows the correct application of Nägele's Rule. Subtracting three months from August 10 gives us May 10, and then adding seven days gives us May 17as the estimated date of delivery.
Correct Answer is A
Explanation
Choice A rationale:
Vibroacoustic stimulation is an appropriate action to perform during a nonstress test if there are no fetal heart rate accelerations. It involves using sound or vibration to stimulate the fetus, potentially eliciting the desired heart rate accelerations.
Choice B rationale:
Placing the client in the Trendelenburg position is not indicated in this situation. It may not benefit the fetus and is not a standard intervention for nonreactive nonstress test results.
Choice C rationale:
Conducting a vaginal exam is not relevant to the situation described in the question. A nonreactive nonstress test does not require a vaginal exam.
Choice D rationale:
Collecting a specimen for an indirect Coombs test is not necessary for this scenario. The test result would not provide information relevant to the nonreactive nonstress test.
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