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 hr.

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

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

The correct answer is choice C, Ensure the newborn's eyes are closed beneath the shield. Phototherapy is a treatment used to reduce high bilirubin levels in newborns. It involves exposing the newborn's skin to special lights, which helps to break down the excess bilirubin in the blood. It is important to ensure that the newborn's eyes are closed beneath the shield to prevent damage to the eyes from the bright lights. Giving the newborn 1 oz of glucose water every 4 hr, applying lotion to the newborn's skin every 8 hr, and dressing the newborn in a thin layer of clothing during therapy are not indicated interventions during phototherapy.

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Correct Answer is C

Explanation

make a loud noise above the newborn. The Moro reflex is elicited by making a loud noise above the newborn or allowing the newborn's head to drop slightly. The newborn will respond by extending and abducting the arms, and then bringing them back to the body, followed by crying. This reflex should be present in a term newborn and is an indication of neurological health.

A. Right upper quadrant B. left upper quadrant C. left lower quadrant. D. right lower quadrant.

Correct Answer is C

Explanation

A.This would be appropriate if the fetus were in a breech presentation.

B.This is incorrect because the fetal back is in the lower left quadrant, not the upper quadrant.

C.In the Left Occipitoanterior (LOA) Position, the fetal occiput (back of the head) is facing the mother’s left side and anteriorly (toward the front of the uterus). The fetal back will be on the left side of the maternal abdomen, making the PMI in the left lower quadrant. The best location to place the fetal monitor is over the fetal back, closest to the head. Since the fetus is cephalic (head down) in LOA position, the heart sounds are heard in the left lower quadrant.

D.This would be appropriate if the fetus were in a right occipitoanterior (ROA) position, but in LOA, the back is on the left.

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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

A nurse is assessing the reflexes of a term newborn. After placing the newborn in the supine position, which of the following methods should the nurse use to elicit the Moro reflex?

Correct Answer is C

Explanation

A nurse is assessing a client who is at 39 weeks of gestation and determines that the fetus is in a left occipitoanterior position. On which of the following sites should the nurse place the external fetal monitor to hear the point of maximum impulse of the fetal heart rate?

Correct Answer is C

Explanation

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