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?
Keep the newborn supine throughout treatment.
Dress the newborn in lightweight clothing.
Measure the newborn's temperature every 8 hr.
Avoid using lotion or ointment on the newborn's skin.
The Correct Answer is D
A. It is essential to regularly reposition the newborn (every 2-3 hours) to ensure even exposure to the phototherapy light and to prevent pressure sores. Keeping the newborn supine throughout the treatment is not recommended.
B. The newborn should be undressed, except for a diaper, during phototherapy to maximize skin exposure to the light. Lightweight clothing can reduce the effectiveness of the treatment.
C. Temperature monitoring should be more frequent than every 8 hours. Phototherapy can cause fluctuations in the newborn's temperature, including overheating or hypothermia, so checking every 2-4 hours is generally recommended.
D. Lotions or ointments should not be applied to the newborn's skin during phototherapy because they can absorb heat, potentially leading to burns or skin irritation. Phototherapy can dry out the skin, but moisturizing treatments should be avoided during the therapy itself.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
The mother is Rh negative and the father is Rh positive. Hemolytic disease of the newborn (HDN) is caused by an incompatibility between the blood types of the mother and fetus. Specifically, it occurs when a Rh-negative mother carries a fetus who is Rh-positive, and the mother's immune system produces antibodies against the Rh antigen on the fetal red blood cells. These antibodies can cross the placenta and destroy the fetal red blood cells, leading to anemia and other complications in the newborn. If a mother has Rhnegative blood, it means that she lacks the Rh antigen on her red blood cells. If the father has Rh-positive blood, there is a chance that the fetus will inherit the Rh antigen from the father. If the fetal Rh-positive blood enters the mother's bloodstream during pregnancy or delivery, the mother's immune system can produce antibodies against the Rh antigen, causing HDN in subsequent pregnancies with Rh-positive fetuses.
Correct Answer is C
Explanation
A. While contact precautions may be necessary for certain infections, they are not specifically required for an HIV-positive mother’s newborn if the infant is not infected. The newborn’s HIV status should be confirmed through testing.
B. IV antibiotics are not routinely administered to newborns of HIV-positive mothers unless there is a specific indication for infection prevention or treatment.
C. It is crucial to clean the newborn promptly after delivery to reduce the risk of HIV transmission, as HIV can be present in blood and other bodily fluids. Proper cleansing helps minimize the risk of exposure.
D. Breastfeeding is contraindicated for mothers with HIV because HIV can be transmitted through breast milk. Instead, formula feeding is recommended to prevent transmission.
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