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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Free Nursing Study Resources

Correct Answer is A, B, D, C

Explanation

Compressing the bulb syringe before placing it in the newborn's mouth or nose creates a vacuum that allows the suctioning of the mucus¹².
Placing the bulb syringe in the newborn's mouth first helps clear the oral airway and prevent aspiration of mucus into the lungs¹². The nozzle of the bulb syringe should be gently inserted into the corner of the mouth, not the center, to avoid stimulating the gag reﬂex¹².
Using the bulb syringe to suction the newborns nose helps clear the nasal airway and improve breathing¹². The nozzle of the bulb syringe should be gently inserted into one nostril at a time, and not too far, to avoid injuring the nasal mucosa¹².
Assessing the newborn for reﬂex bradycardia helps monitor for any adverse eﬀects of suctioning, such as a decrease in heart rate due to vagal stimulation¹³. Reﬂex bradycardia can cause hypoxia and acidosis in newborns, and may require oxygen administration or resuscitation³. The normal heart rate for a newborn is 120 to 160 beats per minute³.

A. Deep tendon reﬂexes of 2+ B. Blood glucose 110 mg/dL C. Urine protein of 3+ D. Hemoglobin 13 g/dL

Correct Answer is C

Explanation

This is because urine protein of 3+ is a sign of preeclampsia, which is a complication of pregnancy that involves high blood pressure and damage to the kidneys or other organs¹². Preeclampsia can cause serious problems for both the mother and the baby, such as fetal growth restriction, placental abruption, preterm birth, eclampsia, and HELLP syndrome¹². The nurse should report this finding to the provider and monitor the client's blood pressure, reﬂexes, and fetal well-being. The client may need medication to lower blood pressure and prevent seizures, such as magnesium sulfate or antihypertensives¹².

The other options are not correct because:
a) Deep tendon reﬂexes of 2+ are normal and do not indicate preeclampsia. Deep tendon reﬂexes are graded from 0 to 4+, with 2+ being the average response⁶. Increased reﬂexes (3+ or 4+) may suggest hyperreﬂexia, which can be a sign of preeclampsia or magnesium toxicity¹⁶.
b) Blood glucose of 110 mg/dL is normal and does not indicate preeclampsia. Blood glucose is the amount of sugar in the blood, and it can vary depending on the time of day, diet, and activity level. The normal range for blood glucose is 70 to 130 mg/dL before meals and less than 180 mg/dL after meals⁷. High blood glucose (hyperglycemia) can be a sign of gestational diabetes, which is a type of diabetes that develops during pregnancy⁷.
d) Hemoglobin of 13 g/dL is normal and does not indicate preeclampsia. Hemoglobin is the protein in red blood cells that carries oxygen throughout the body. The normal range for hemoglobin is 12 to 16 g/dL for women and 14 to 18 g/dL for men⁷. Low hemoglobin (anemia) can be a sign of iron deficiency, bleeding, or infection⁷.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Correct Answer is A, B, D, C

Explanation

A nurse is assessing a client who has preeclampsia during a prenatal visit. Which of the following findings should the nurse report to the provider?

Correct Answer is C

Explanation

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