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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Uterine atony is a condition in which the uterus does not contract properly after delivery, leading to excessive bleeding or postpartum hemorrhage. Uterine atony can be caused by various factors, such as
prolonged or fast labor, multiple gestation, large baby, polyhydramnios, infection, or use of certain medications¹.
The nurse should monitor the client for any signs of uterine atony, such as:
- A soft or boggy uterus that does not respond to massage
- Excessive bleeding or clots from the vagina
- Low blood pressure or fast pulse
- Pale or clammy skin
- Dizziness or fainting
The nurse should also provide immediate interventions to stop the bleeding and restore uterine tone, such
as:
- Massaging the uterus firmly until it contracts
- Administering uterotonic medications as ordered to stimulate uterine contractions
- Administering intravenous fluids and blood products as needed to replace blood loss
- Notifying the provider and preparing for possible surgical procedures if bleeding persists
Uterotonic medications are drugs that cause the uterus to contract and reduce bleeding. They are used to prevent or treat postpartum hemorrhage due to uterine atony. The most common uterotonic medications are:
- Oxytocin: a hormone that is naturally produced by the body during labor and breastfeeding. It is the first- line drug for uterine atony and is given intravenously or intramuscularly. It causes strong and sustained contractions of the uterus and also reduces blood pressure and pain. It has few side effects, but it can cause water retention, nausea, vomiting, or headache in high doses²³.
- Methylergonovine: a synthetic derivative of ergot, a fungus that grows on rye. It is a second-line drug for uterine atony and is given intramuscularly or orally. It causes prolonged contractions of the uterus and also constricts blood vessels in other parts of the body. It can cause side effects such as hypertension, headache, nausea, vomiting, chest pain, or allergic reactions. It is contraindicated in clients with hypertension, preeclampsia, cardiac disease, or liver disease²³.
- Carboprost: a synthetic form of prostaglandin F2 alpha, a hormone that regulates inflammation and blood clotting. It is a third-line drug for uterine atony and is given intramuscularly. It causes intense contractions of the uterus and also relaxes smooth muscles in other parts of the body. It can cause side effects such as fever, diarrhea, nausea, vomiting, bronchospasm, or allergic reactions. It is contraindicated in clients with asthma, liver disease, or kidney disease²³.
- Misoprostol: a synthetic form of prostaglandin E1, a hormone that protects the stomach lining from ulcers. It is an alternative drug for uterine atony and is given orally, rectally, sublingually, or vaginally. It causes mild to moderate contractions of the uterus and also dilates blood vessels in other parts of the body. It can cause side effects such as fever, chills, shivering, nausea, vomiting, diarrhea, or abdominal pain. It is contraindicated in clients with allergy to prostaglandins²³.
Therefore, the nurse should anticipate the use of methylergonovine for a client who has uterine atony that does not respond to oxytocin administration. The nurse should also monitor the client's blood pressure and vital signs closely and report any adverse reactions to the provider.
The other options are not medications that the nurse should anticipate the use of for uterine atony:
- a) Terbutaline is a medication that belongs to a class of drugs called beta-adrenergic agonists. It is used to relax the smooth muscles of the bronchi and uterus. It is used to treat asthma and preterm labor by preventing or stopping contractions. It is not indicated for uterine atony and can cause side effects such as tachycardia, palpitations, tremors, anxiety or hypotension²⁴.
- c) Hydralazine is a medication that belongs to a class of drugs called vasodilators. It is used to lower blood pressure by relaxing the smooth muscles of the arteries. It is used to treat hypertension and preeclampsia by reducing vascular resistance and improving blood flow. It is not indicated
Correct Answer is A
Explanation
Urination is an important indicator of a newborn's hydration and kidney function. A newborn should urinate at least six times a day, or once every four hours, by the fifth day of life. The urine should be clear or pale yellow and have no strong odor or blood. A newborn who urinates less than six times a day may be dehydrated, have a urinary tract infection, or have a kidney problem .
Therefore, the nurse should instruct the client to monitor her baby's urination and notify the pediatrician if he urinates less than six times a day. The nurse should also teach the client how to prevent dehydration in her baby, such as:
- Feeding the baby frequently, either breast milk or formula, according to his hunger cues and weight gain
- Offering the baby extra fluids in hot weather or when he is sick
- Avoiding giving the baby water, juice, or cow's milk before six months of age
- Checking the baby's diapers for wetness and changing them promptly
- Checking the baby's mouth for dryness and his fontanelle for sunkenness
The other statements are not correct and should not be made by the nurse:
- b) "Swaddle your baby tightly with his legs extended before laying him down to sleep." This is not correct because swaddling a baby too tightly or with his legs extended can cause problems, such as overheating, hip dysplasia, or restricted breathing. The nurse should teach the client how to swaddle her baby safely and comfortably, such as:
- Using a thin blanket that is breathable and does not cover the baby's head or face
- Wrapping the blanket snugly around the baby's chest and arms, but leaving some room for his hips and legs to move freely
- Placing the baby on his back to sleep on a firm and flat surface with no pillows, blankets, or toys
- Stopping swaddling when the baby shows signs of rolling over or breaking free from the blanket
c) "Place triple antibiotic ointment on your baby's umbilical cord twice per day." This is not correct because placing ointment on the umbilical cord can delay its healing and increase the risk of infection. The nurse should teach the client how to care for her baby's umbilical cord until it falls off naturally, usually within one to two weeks after birth, such as:
- Keeping the cord clean and dry by using a cotton swab dipped in water or alcohol to gently wipe around it
- Folding the diaper below the cord to prevent irritation or wetness
- Dressing the baby in loose-fitting clothes that allow air circulation around the cord
- Avoiding bathing the baby in a tub until the cord falls off and heals
- Watching for any signs of infection, such as redness, swelling, pus, foul odor, or bleeding
d) "Retract the foreskin to clean your baby's penis during each bath." This is not correct because retracting the foreskin of a newborn can cause pain, injury, or infection. The foreskin of a newborn is usually attached to the head of the penis (glans) and does not need to be retracted for cleaning. The nurse should teach the client how to clean her baby's penis during each bath, such as:
- Using warm water and mild soap to gently wash the outside of the penis
- Rinsing well and patting dry with a soft towel
- Leaving the foreskin alone and never forcing it back
- Changing diapers frequently and keeping them clean and dry
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