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 hours.

Avoid using lotion or ointment on the newborn's skin.

Answer and Explanation

The Correct Answer is D

Phototherapy is a treatment that uses light to lower the level of bilirubin in the blood of newborns who have jaundice. Jaundice is a condition that causes yellowing of the skin and eyes due to high levels of bilirubin, a waste product that is normally removed by the liver. Phototherapy helps the body break down and eliminate bilirubin through urine and stool¹.
Phototherapy can be done at home or in the hospital, depending on the severity of jaundice and the type of light used. The most common types of light are ﬂuorescent lamps, halogen lamps, or light-emitting diodes (LEDs). The light can be delivered through overhead units, fiber-optic blankets, or fiber-optic pads. The light should cover as much of the newborn's skin as possible, except for the eyes and genitals¹².

The nurse should follow certain guidelines when caring for a newborn who is receiving phototherapy, such
as:
-   Monitor the newborn's temperature, hydration, weight, and urine and stool output regularly
-   Protect the newborn's eyes with eye patches or goggles to prevent eye damage
-   Turn the newborn every 2 to 4 hours to expose diﬀerent parts of the body to the light
-   Feed the newborn frequently to prevent dehydration and promote bilirubin excretion

-   Check the newborn's skin color and bilirubin level periodically to evaluate the eﬀectiveness of
phototherapy
-   Provide emotional support and education to the parents about jaundice and phototherapy
One of the important guidelines is to avoid using lotion or ointment on the newborn's skin during phototherapy. This is because lotion or ointment can block the light from reaching the skin and reduce the eﬀectiveness of phototherapy. Lotion or ointment can also cause skin irritation, rash, or burns if they react with the light. The newborn's skin should be clean and dry before phototherapy¹²³.

The other options are not actions that the nurse should include in the plan of care:
-   a) Keep the newborn supine throughout treatment. This is not correct because keeping the newborn in one position can limit the exposure of diﬀerent parts of the body to the light and reduce the eﬀectiveness of phototherapy. The nurse should turn the newborn every 2 to 4 hours to expose diﬀerent parts of the body to the light¹².
-   b) Dress the newborn in lightweight clothing. This is not correct because dressing the newborn in clothing can block the light from reaching the skin and reduce the eﬀectiveness of phototherapy. The newborn should be undressed except for a diaper during phototherapy¹².
-   c) Measure the newborn's temperature every 8 hours. This is not correct because measuring the newborn's temperature every 8 hours may not be frequent enough to detect any changes in temperature that may occur during phototherapy. Phototherapy can cause overheating or hypothermia in newborns, depending on the type and intensity of light used. The nurse should monitor the newborn's temperature more often, such as every 2 to 4 hours, and adjust the room temperature or use blankets as needed¹².

Nursing Test Bank

Test Bank #1: RN Pharmacology Exams Test Bank #2: RN Medical-Surgical Exams Test Bank #3: RN Fundamentals Exams Test Bank #4: RN Maternal-Newborn Exams Test Bank #5: RN Anatomy and Physiology Exams Test Bank #6: RN Obstetrics and Pediatrics Exams Test Bank #7: RN Fluid and Electrolytes Exams Test Bank #9: RN Adult Health Test Bank #10: RN Dosage Calculation Test Bank #11: RN Community Health Exams Test Bank #12: RN Psychology Exams Test Bank #13: RN Nursing Care Of Children Test Bank #14: RN Foundations of Nursing Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Exam #1: RN Comprehensive predictor 2023 proctored exam Exam #2: Ati rn vati comprehensive predictor proctored exam Exam #3: Ati Rn Comprehensive Predictor Proctored Exam 2023 Exam #4: Rn Comprehensive Predictor 2023 Proctored Exam - St. Joseph Exam #5: RN Comprehensive Predictor Proctored Exam (National U CA San Diego) Exam #6: Ati rn comprehensive predictor 2023 retake proctored exam Exam #7: RN Hesi Exit Proctored Exam Exam #8: Hesi RN Exit proctored exam Exam #9: Hesi rn exit proctored exam Exam #10: Hesi Rn compass exit B proctored exam

Free Nursing Study Resources

Correct Answer is D

Explanation

A pudendal nerve block is a local anesthetic administered to block the pudendal nerve, which supplies sensation to the perineum and external genitalia. It is commonly used during childbirth to provide pain relief during the second stage of labor.

An adverse eﬀect of a pudendal nerve block is a decreased ability to bear down, or a decreased ability to push eﬀectively during labor. This is because the block aﬀects the nerves responsible for the contraction of the pelvic ﬂoor muscles, which are necessary for eﬀective pushing during delivery.

Option a) Uterine hyperstimulation is not an adverse eﬀect of a pudendal nerve block. Uterine hyperstimulation refers to excessive contractions of the uterus, often caused by medications such as oxytocin. Pudendal nerve block does not directly aﬀect uterine contractions.

Option b) Maternal hypertension is not an adverse eﬀect of a pudendal nerve block. Hypertension refers to

high blood pressure, and it is not typically associated with a pudendal nerve block.

Option c) Fetal bradycardia is not a common adverse eﬀect of a pudendal nerve block. Fetal bradycardia refers to a slow heart rate in the fetus. While fetal heart rate monitoring is important during labor, bradycardia is not typically associated with a pudendal nerve block.

A. The newborn's pulse oximetry is 91% B. The newborn's respiratory rate is irregular C. The newborn is beginning to cough D. The newborn's respiratory rate is 32/min

Correct Answer is A

Explanation

This is because a low pulse oximetry reading can indicate that the newborn is hypoxic and needs suctioning of the nasopharynx to clear any secretions that may be obstructing the airway²⁴. Hypoxia can cause bradycardia, acidosis, and brain injury in newborns, and should be corrected as soon as possible². The normal range of pulse oximetry for a newborn is 95% to 100%².

The other options are not correct because:
b) The newborn's respiratory rate is irregular
This is not a sign that suctioning is needed, as it is a normal finding in newborns. Newborns have periodic breathing patterns, which involve alternating periods of rapid and slow breathing, with occasional pauses of up to 10 seconds². This does not indicate respiratory distress or hypoxia, and does not require intervention unless the pauses are longer than 10 seconds or associated with cyanosis or bradycardia².
c) The newborn is beginning to cough
This is not a sign that suctioning is needed, as it is a normal reﬂex that helps the newborn clear the airway of secretions. Coughing can also stimulate breathing and prevent apnea in newborns². Coughing does not indicate respiratory distress or hypoxia, and does not require intervention unless it is persistent or associated with other signs of respiratory compromise².
d) The newborn's respiratory rate is 32/min
This is not a sign that suctioning is needed, as it is within the normal range for a newborn. The normal respiratory rate for a newborn is 30 to 60 breaths per minute². A respiratory rate that is too high or too low can indicate respiratory distress or hypoxia, and may require suctioning or other interventions².

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

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 client who has had a pudendal nerve block. The nurse should monitor for which of the following findings as an adverse eﬀect?

Correct Answer is D

Explanation

A nurse is caring for a newborn. Which of the following assessment findings should indicate to the nurse that suctioning of the nasopharynx is needed?

Correct Answer is A

Explanation

A nurse is reviewing the laboratory report for a client who is in active labor. The client tested positive for Group B Streptococcus β-hemolytic. Which of the following medications should the nurse plan to administer to the client?

A nurse is providing teaching to a client about postpartum care. Which of the following information should the nurse include?

A nurse is providing teaching to a client who reports that her baby has yellow discharge forming at the circumcision site. Which of the following is an appropriate response by the nurse?

A nurse is planning care for a newborn who is scheduled to start phototherapy using a lamp. Which of the following actions should the nurse include in the plan?

A nurse is teaching a prenatal client about listeriosis and dietary modifications during pregnancy. Which of the following statements by the client indicates an understanding of the teaching?

A nurse is assessing a client who is 6 hours postpartum and has endometritis. Which of the following findings should the nurse expect?

A nurse is assessing a newborn whose mother had a primary cytomegalovirus (CMV) infection during pregnancy. The newborn acquired CMV transplacentally. Which of the following findings should the nurse expect the newborn to exhibit?