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?

Give the newborn 1 oz of glucose water every 4 hours.

Apply a thin layer of lotion to the newborn's skin every 8 hours.

Ensure the newborn's eyes are closed beneath the shield.

Dress the newborn in a thin layer of clothing during therapy.

Answer and Explanation

The Correct Answer is C

Phototherapy is a treatment method used to reduce high levels of bilirubin in the blood of a newborn with jaundice. During phototherapy, the newborn is exposed to special lights that help break down the bilirubin and allow it to be eliminated from the body. It is important to protect the newborn's eyes during phototherapy.

Option a) Giving the newborn 1 oz of glucose water every 4 hours is not necessary for phototherapy. The primary goal of phototherapy is to treat jaundice, and providing glucose water is not directly related to this treatment.

Option b)Applying a thin layer of lotion to the newborn's skin every 8 hours is not necessary during phototherapy. In fact, it is generally recommended to avoid applying lotions or oils to the skin during phototherapy as they can interfere with the eﬀectiveness of the treatment.

Option c) Ensuring the newborn's eyes are closed beneath the shield is essential during phototherapy. The eyes are particularly sensitive to the light used in phototherapy, and exposure to the light can potentially damage the eyes. Therefore, the newborn's eyes should be protected with a shield or eye patches to prevent direct exposure to the light.

Option d) Dressing the newborn in a thin layer of clothing during therapy is appropriate. The newborn should be dressed in a way that allows as much of their skin as possible to be exposed to the phototherapy lights. This usually involves removing unnecessary clothing and covering the genital area with a diaper, while the rest of the body is exposed to the light.

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Correct Answer is B

Explanation

An ectopic pregnancy is a pregnancy that occurs outside the uterus, usually in the fallopian tube. The most common manifestation of an ectopic pregnancy is sharp pelvic pain, typically on one side. This pain is often described as severe and may be accompanied by shoulder pain or dizziness. The pain occurs because the fallopian tube is not designed to accommodate a growing embryo, leading to stretching and possible rupture of the tube.

Elevated blood pressure is not typically associated with an ectopic pregnancy. Blood pressure changes may occur in other conditions, such as preeclampsia, but it is not a characteristic manifestation of an ectopic pregnancy.

Bright red vaginal discharge is not a typical manifestation of an ectopic pregnancy. Vaginal bleeding may occur, but it is usually darker and more like a menstrual ﬂow. Bright red vaginal discharge may indicate other conditions, such as a threatened miscarriage or a vaginal infection.

A scaphoid abdomen (a concave or sunken appearance of the abdomen) is not a specific manifestation of an ectopic pregnancy. It may be seen in conditions like malnutrition or dehydration, but it is not directly related to an ectopic pregnancy.

A. Cleanse the newborn immediately after delivery. B. Initiate contact precautions for the newborn. C. Administer intravenous antibiotics to the newborn. D. Encourage the mother to breastfeed her newborn.

Correct Answer is A

Explanation

A newborn who is exposed to HIV perinatally should be bathed and cleansed of maternal secretions as soon as possible after birth to reduce the risk of HIV transmission through the skin or mucous membranes¹². The newborn should also receive antiretroviral prophylaxis within six hours of delivery, preferably within two hours¹². The type and duration of prophylaxis depend on the maternal and infant factors that inﬂuence the risk of HIV transmission, such as maternal viral load, antiretroviral therapy, mode of delivery, and infant gestational age¹²³. The newborn should also undergo HIV testing at birth, at 14 to 21 days of age, at one to two months of age, and at four to six months of age¹².

The other options are incorrect because:
b) Initiating contact precautions for the newborn is not necessary or recommended. Contact precautions are used to prevent the spread of infections that are transmited by direct or indirect contact with the patient or the patient's environment. HIV is not transmited by casual contact, and standard precautions are sufficient to prevent exposure to blood or body ﬂuids that may contain HIV¹².
c) Administering intravenous antibiotics to the newborn is not indicated for HIV prevention. Antibiotics are used to treat bacterial infections, not viral infections like HIV. Antibiotics may be given to the newborn for other reasons, such as suspected sepsis or chorioamnionitis, but they do not aﬀect the risk of HIV transmission¹².
d) Encouraging the mother to breastfeed her newborn is contraindicated for HIV prevention. Breastfeeding can transmit HIV from the mother to the infant through breast milk, especially if the mother has a high viral load, mastitis, cracked nipples, or oral lesions in the infant. In resource-limited settings where formula feeding may not be feasible or safe, breastfeeding with maternal or infant antiretroviral therapy may be considered, but in developed countries where safe alternatives are available, breastfeeding is not recommended for mothers with HIV infection¹².

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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?

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Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who is at 8 weeks of gestation and has an ectopic pregnancy. Which of the following manifestations should the nurse expect?

Correct Answer is B

Explanation

A nurse on the labor and delivery unit is planning care for a client who has human immunodeficiency virus (HIV). Which of the following is an appropriate action for the nurse to take following the birth of the newborn?

Correct Answer is A

Explanation

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