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.

Answer and Explanation

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.

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Free Nursing Study Resources

Correct Answer is D,C,B,A

Explanation

The correct sequence for suctioning a newborn with a bulb syringe, according to the information provided, is as follows: 1. Compress the bulb syringe (d) to expel the air. 2. Place the bulb syringe in the newborn’s mouth © to suction the mucus. 3. Use the bulb syringe to suction the newborn’s nose (b) after the mouth has been cleared. 4. Assess the newborn for reflex bradycardia (a) following the suctioning. This sequence ensures that the airway is cleared effectively and safely, minimizing the risk of inducing bradycardia by stimulating the vagus nerve during suctioning. Always remember to perform these steps gently and to follow the guidelines and protocols of your healthcare facility.

A. "The nurse should determine the Apgar score at 2 and 7 minutes after birth.”. B. "The nurse should identify that the newborn is in severe distress with an Apgar score of 8.”. C. "The nurse should wait for the first Apgar score before initiating resuscitation efforts.”. D. "The nurse should measure the newborn's muscle tone when assigning an Apgar score.".

Correct Answer is D

Explanation

The correct answer is choice d. “The nurse should measure the newborn’s muscle tone when assigning an Apgar score.”

Choice A rationale:

The Apgar score is determined at 1 and 5 minutes after birth, not at 2 and 7 minutes.

Choice B rationale:

An Apgar score of 8 indicates that the newborn is in good health, not severe distress. Scores of 7-10 are considered normal.

Choice C rationale:

Resuscitation efforts should not be delayed until the first Apgar score is obtained. Immediate resuscitation is initiated if needed, regardless of the Apgar score.

Choice D rationale:

Muscle tone is one of the five criteria assessed in the Apgar score, along with appearance, pulse, grimace, and respiration.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a newborn immediately following birth and notes a large amount of mucus in the newborn's mouth and nose. Identify the sequence the nurse should follow when performing suction with a bulb syringe.

Correct Answer is D,C,B,A

Explanation

A nurse is teaching a newly hired nurse about Apgar scoring. Which of the following statements by the newly hired nurse indicates an understanding of the teaching?

Correct Answer is D

Explanation

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