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.

Answer and Explanation

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.

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Correct Answer is D

Explanation

A. A blood glucose level of 120 mg/dL is within the expected range for a client receiving total parenteral nutrition and does not require immediate intervention.

B. A serum sodium level of 138 mEq/L is within the normal range and does not require immediate intervention.

C. An oral temperature of 37.6°C (99.7°F) is slightly elevated but may be within the client's normal range and does not require immediate intervention unless accompanied by other signs of infection.

D. A weight increase of 2 kg (4.4 lb) in the past 24 hours indicates fluid overload, which can lead to complications such as heart failure or pulmonary edema. Immediate intervention, such as adjusting the rate of fluid administration or notifying the healthcare provider, is necessary to prevent further complications.

A. Determine the client's pain level. B. Irrigate the wound with 0.9% sodium chloride irrigation. C. Apply skin preparation to wound edges. D. Don sterile gloves.

Correct Answer is A

Explanation

A. Assessing the client's pain level is the first step to ensure appropriate pain management during the procedure.

B. Irrigating the wound comes after assessing the client's pain level and preparing the wound for the dressing change.

C. Applying skin preparation to wound edges is part of the preparation process but should come after assessing the client's pain level.

D. Donning sterile gloves is necessary for the procedure but should come after assessing the client's pain level.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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