A nurse is planning care for a newborn who has hyperbilirubinemia and is receiving phototherapy.
Which of the following interventions should the nurse include in the plan?
Monitor skin temperature every hour
Cover genitalia with a diaper or cloth
Reposition newborn every 4 hours
Encourage parent-infant interaction as tolerated
The Correct Answer is B
This is because phototherapy can cause dehydration and increase insensible water loss, so covering the genitalia can prevent excessive fluid loss and maintain thermoregulation.
Some possible explanations for the other choices are:
• Choice A is wrong because monitoring skin temperature every hour is not enough to prevent hyperthermia or hypothermia during phototherapy. The skin temperature should be monitored continuously or at least every 15 minutes.
• Choice C is wrong because repositioning newborn every 4 hours is not frequent enough to prevent pressure ulcers, skin breakdown, or eye damage from the light source. The newborn should be repositioned at least every 2 hours.
• Choice D is wrong because encouraging parent-infant interaction as tolerated is not a specific intervention for phototherapy.
While parent-infant interaction is important for bonding and development, it should not interfere with the effectiveness of phototherapy. The newborn should be exposed to the light as much as possible, except for feeding and diaper changes.
Normal ranges for serum bilirubin levels vary depending on the age, gestational age, and risk factors of the newborn. Generally, the levels should be below 5 mg/dL for term infants and below 7 mg/dL for preterm infants by the fifth day of life.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
This is a sign of dehydration, which can be caused by phototherapy.Phototherapy increases insensible water loss through the skin and can lead to fluid and electrolyte imbalance in the newborn.The nurse should monitor the newborn’s hydration status, weight, urine output, and serum electrolytes and provide adequate fluid intake.
Choice A is wrong because conjunctivitis is not a common complication of phototherapy.It can be prevented by using eye shields or patches to protect the newborn’s eyes from the light source.
Choice B is wrong because bronze skin discoloration is a rare complication of phototherapy that occurs when the bilirubin level is very high and the skin pigment changes.It is not a priority finding and usually resolves after phototherapy is discontinued.
Choice D is wrong because maculopapular skin rash is a benign side effect of phototherapy that does not require intervention.It usually disappears within a few days after phototherapy is stopped.
Correct Answer is D
Explanation
Phototherapy is a treatment that uses light to break down bilirubin in the blood and make it easier for the liver to eliminate it.
Phototherapy is effective when:
• The bilirubin levels decrease within 24 hours of treatment.
This means that the bilirubin is being cleared faster than it is being produced.
• The urine output and stool frequency increase during treatment.
This means that the bilirubin is being excreted through the kidneys and intestines.
• The skin color and muscle tone improve after treatment.
This means that the bilirubin is no longer causing jaundice or affecting the nervous system.
Statement A is wrong because it only describes one aspect of phototherapy effectiveness.
Statement B is wrong because it only describes another aspect of phototherapy effectiveness.
Statement C is wrong because it only describes the outcome of phototherapy effectiveness.
Statement D is correct because it includes all three aspects of phototherapy effectiveness.
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