A nurse is planning care for a newborn who has hyperbilirubinemia and is to receive phototherapy. Which of the following interventions should the nurse include?
Clothe the newborn in light cotton.
Check the newborn's temperature every 8 hr.
Administer 120 mL (4 oz) of water between feedings.
Place the newborn 45 cm (18 in) from the light source.
The Correct Answer is D
- A. Clothing the newborn in light cotton is not recommended because it can block the light from reaching the skin, which is necessary for the treatment of hyperbilirubinemia through phototherapy.
- B. Checking the newborn's temperature every 8 hours is not frequent enough; during phototherapy, it is important to monitor the newborn's temperature more frequently to ensure they do not become too cold or too warm as a result of the therapy.
- C. Administering water between feedings is not recommended as it can interfere with the newborn's feeding schedule and nutrition; breast milk or formula provides adequate hydration unless otherwise indicated by a healthcare provider.
- D. Placing the newborn 45 cm (18 in) from the light source is the correct intervention. This distance allows for optimal exposure to the light while ensuring the safety and comfort of the newborn, as recommended in clinical guidelines for effective phototherapy.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. The provider is not required to notify the client's employer about the admission to a mental health facility. This information is protected under confidentiality laws and regulations.
B. While the client may be strongly encouraged to take prescribed medications, they cannot be forced to do so without consent, especially if they are competent to make their own decisions.
C. Electroconvulsive therapy (ECT) typically requires informed consent from the patient or their legal representative, even in an involuntary admission scenario. Therefore, it is incorrect to state that ECT can be performed without consent.
D. If the client poses a risk of harm to themselves or others, the provider can prescribe restraints as a safety measure. This statement is correct and aligns with safety protocols in mental health facilities.
Correct Answer is B
Explanation
A. Speaking directly into one of the client's ears may not effectively improve communication for someone with a hearing impairment, especially if the impairment is bilateral.
B. Rephrasing sentences the client does not understand can help improve comprehension by providing information in a different way.
C. Dropping voice volume at the end of sentences may make it difficult for the client to hear the end of the sentence, especially if they have a hearing impairment.
D. Exaggerating lip movements may not be helpful and can actually make lip-reading more difficult for some individuals.
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