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.
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
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Bladder distention is a common postpartum complication that can occur due to decreased bladder sensation, perineal edema, trauma, or pain after vaginal birth. Bladder distention can interfere with uterine contraction and involution, leading to increased bleeding and risk of infection. Therefore, it is important to assess and manage bladder distention promptly and effectively in postpartum clients.
The first action the nurse should take for a client who has bladder distention is to assist the client to the bathroom and encourage voiding. This is the least invasive and most natural way to empty the bladder and relieve the distention. The nurse should provide privacy, comfort, and support to the client, and help with perineal care after voiding. The nurse should also measure the urine output and monitor for signs of urinary retention or infection, such as dribbling, frequency, urgency, dysuria, hematuria, or foul-smelling urine.
b) Inserting a urinary catheter is not the first action the nurse should take for a client who has bladder distention. A urinary catheter is an invasive procedure that can introduce infection, trauma, or irritation to the urinary tract. It should be used only as a last resort when other methods of bladder emptying have failed or are contraindicated. The nurse should obtain a provider's order before inserting a urinary catheter and follow strict aseptic technique.
c) Offering the client a sitz bath is not the first action the nurse should take for a client who has bladder distention. A sitz bath is a warm water bath that covers only the hips and buttocks. It can provide comfort and promote healing for clients who have perineal lacerations, episiotomies, or hemorrhoids after vaginal birth. However, it does not directly address bladder distention or facilitate voiding. It may also increase the risk of infection or bleeding if done too soon or too frequently after delivery.
d) Pouring warm water over the client's perineum is not the first action the nurse should take for a client who has bladder distention. Pouring warm water over the perineum can help with perineal care and hygiene after vaginal birth. It can also stimulate voiding by creating a relaxing effect on the pelvic floor muscles. However, it does not ensure complete bladder emptying or relieve bladder distention. It may also cause discomfort or irritation if the water temperature or pressure is too high.
Correct Answer is C
Explanation
A client who has had two prior cesarean births is at an increased risk for uterine rupture during labor. Uterine rupture is a serious complication in which there is a complete or partial tear in the uterine wall, potentially leading to significant maternal and fetal morbidity or mortality.
The risk of uterine rupture increases with each prior cesarean birth due to the presence of a scar on the uterus. The scar tissue is weaker than the normal uterine tissue and can potentially rupture during contractions and labor. The risk of uterine rupture is particularly high if the client attempts a vaginal birth after cesarean (VBAC).
Option a) Precipitous labor refers to an extremely fast labor that lasts less than three hours from the onset of contractions to birth. While clients with prior cesarean births may be at increased risk for certain complications, such as uterine rupture, it does not necessarily increase the risk of precipitous labor.
Option b) Abruptio placentae is the premature separation of the placenta from the uterine wall before the birth of the baby. While it is a potential complication during pregnancy, it is not directly associated with prior cesarean births.
Option d) Failure to progress refers to a lack of cervical dilation or descent of the baby during labor. While prior cesarean births can increase the risk of certain labor complications, such as uterine rupture, they do not necessarily increase the risk of failure to progress.
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