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.
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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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
The Apgar score is a method for assessing the health and well-being of a newborn baby immediately after birth. It is based on five criteria: appearance (skin color), pulse (heart rate), grimace (reflex irritability), activity (muscle tone), and respiration (breathing effort). Each criterion is given a score of 0, 1, or 2, depending on the baby's condition. The total score ranges from 0 to 10, with higher scores indicating better health. The Apgar score is determined at one and five minutes after birth, and sometimes at 10 minutes if the score is low or the baby needs resuscitation. The purpose of the Apgar score is to identify babies who need immediate medical attention and to monitor their response to treatment. The Apgar score is not a predictor of long-term outcomes or developmental problems .
One of the criteria that the nurse should measure when assigning an Apgar score is muscle tone. Muscle tone refers to the degree of tension or stiffness in the baby's muscles. It reflects the baby's neuromuscular function and oxygenation. Muscle tone can be assessed by observing the baby's posture, movement, and resistance to passive flexion or extension of the limbs .
The scoring system for muscle tone is as follows:
- Score 0: No movement; limp and floppy
- Score 1: Some flexion of arms and legs; weak or sluggish movement
- Score 2: Active movement; arms and legs flexed and resist extension
Therefore, the newly hired nurse who says that the nurse should measure the newborn's muscle tone
when assigning an Apgar score indicates an understanding of the teaching.
The other statements show a lack of knowledge or misunderstanding of the Apgar scoring:
- a) "The nurse should determine the Apgar score at 2 and 7 minutes after birth." This is not correct because the standard times for determining the Apgar score are one and five minutes after birth, not two and seven minutes. The one-minute score reflects how well the baby tolerated the delivery process, while the five-minute score reflects how well the baby adapted to the extrauterine environment .
- b) "The nurse should identify that the newborn is in severe distress with an Apgar score of 8." This is not correct because an Apgar score of 8 indicates that the newborn is in good condition and does not need any intervention. An Apgar score of 7 to 10 means that the newborn has normal vital signs and reflexes and only needs routine care. An Apgar score of 4 to 6 means that the newborn has moderate distress and may need some assistance with breathing or stimulation. An Apgar score of 0 to 3 means that the newborn has severe distress and needs immediate resuscitation .
- c) "The nurse should wait for the first Apgar score before initiating resuscitation efforts." This is not correct because waiting for the first Apgar score can delay life-saving interventions for a newborn who needs resuscitation. The nurse should initiate resuscitation efforts as soon as possible if the newborn shows any signs of distress, such as apnea, gasping, cyanosis, bradycardia, or poor muscle tone. The nurse should not rely on the Apgar score alone to decide whether to resuscitate or not, but use it as a tool to monitor the baby's response to treatment .
Correct Answer is ["A","D","E"]
Explanation
These are the findings that place the client at risk for postpartum hemorrhage. Postpartum hemorrhage (PPH) is severe vaginal bleeding after childbirth. It can be a life-threatening condition that requires prompt treatment. The most common cause of PPH is uterine atony, which is when the uterus does not contract enough to stop the bleeding from the placental site¹. Factors that can increase the risk of uterine atony include:
- History of uterine atony: Having a previous episode of PPH due to uterine atony makes it more likely to
happen again in subsequent deliveries.
- Labor induction with oxytocin: Oxytocin is a hormone that stimulates uterine contractions. However, prolonged or excessive use of oxytocin during labor can cause uterine fatigue and reduce its ability to contract after delivery.
- Vacuum-assisted delivery: A vacuum extractor is a device that helps deliver the baby by applying suction to the baby's head. This can cause trauma to the uterus and increase the risk of bleeding.
The other options are not correct because they are not risk factors for postpartum hemorrhage. Let me
explain why:
b) History of human papillomavirus
Human papillomavirus (HPV) is a common sexually transmited infection that can cause genital warts and cervical cancer. However, it does not increase the risk of postpartum hemorrhage. HPV may affect the cervix, but not the uterus or the placenta, which are the main sources of bleeding after delivery³.
c) Newborn weight 2.948 kg (6 Ib 8 oz)
This is a normal newborn weight and does not increase the risk of postpartum hemorrhage. A large baby (more than 4 kg or 8.8 Ib) may increase the risk of uterine atony by overdistending the uterus, but this is not the case for this newborn².
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