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.
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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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
The mother is Rh negative and the father is Rh positive. Hemolytic disease of the newborn (HDN) is caused by an incompatibility between the blood types of the mother and fetus. Specifically, it occurs when a Rh-negative mother carries a fetus who is Rh-positive, and the mother's immune system produces antibodies against the Rh antigen on the fetal red blood cells. These antibodies can cross the placenta and destroy the fetal red blood cells, leading to anemia and other complications in the newborn. If a mother has Rhnegative blood, it means that she lacks the Rh antigen on her red blood cells. If the father has Rh-positive blood, there is a chance that the fetus will inherit the Rh antigen from the father. If the fetal Rh-positive blood enters the mother's bloodstream during pregnancy or delivery, the mother's immune system can produce antibodies against the Rh antigen, causing HDN in subsequent pregnancies with Rh-positive fetuses.
Correct Answer is B
Explanation
Newborns born to mothers with gestational diabetes mellitus are at risk for hypoglycemia, which is a condition characterized by low blood sugar levels. Jitteriness is a common sign of hypoglycemia in newborns. Other signs of hypoglycemia include poor feeding, lethargy, seizures, and apnea.
Choice A, petechiae, refers to small, pinpoint, red or purple spots on the skin caused by bleeding under the skin. It is not a common manifestation of hypoglycemia. Choice C, increased muscle tone, is not a common manifestation of hypoglycemia and may indicate other conditions such as cerebral palsy. Choice D, abdominal distention, may indicate other conditions such as intestinal obstruction or infection, but is not a common manifestation of hypoglycemia.
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