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?
Apply a thin layer of lotion to the newborn's skin every 4 hr.
Give the newborn 1 oz of glucose water every 4 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
Choice A rationale:
The nurse should not apply lotion to the newborn's skin during phototherapy. Phototherapy involves exposing the newborn's skin to light to treat jaundice by breaking down bilirubin. Applying lotion may interfere with the effectiveness of the therapy and may not be recommended as it can make it difficult for the skin to release heat generated during the process.
Choice B rationale:
Giving the newborn glucose water every 4 hours is not a necessary action during phototherapy. The primary concern during phototherapy is to treat jaundice, and giving glucose water may not have a direct impact on the effectiveness of the treatment. Additionally, it is important to focus on monitoring the newborn's bilirubin levels and hydration status.
Choice D rationale:
Dressing the newborn in a thin layer of clothing during phototherapy is not recommended. Phototherapy works best when the newborn's skin is exposed to a light source, and covering the skin with clothing may decrease the effectiveness of the treatment.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale:
This manifestation, urine output of 20 mL/hr, is an adverse reaction to magnesium sulfate administration. Magnesium sulfate can lead to decreased urine output, and it is essential for the nurse to monitor the client's urinary output closely. Low urine output may indicate decreased kidney function, which can be a sign of magnesium toxicity.
Choice B rationale:
Hypertension is expected in a client with preeclampsia, and magnesium sulfate is used to help manage and prevent seizures in these cases. While it is essential to monitor and manage hypertension during pregnancy, it is not considered an adverse reaction to magnesium sulfate.
Choice C rationale:
Hyperglycemia is not a common adverse reaction to magnesium sulfate. Magnesium sulfate may cause central nervous system depression, muscle weakness, and respiratory depression, but it does not typically cause hyperglycemia.
Choice D rationale:
A respiratory rate of 16/min is within the normal range for an adult and is not indicative of an adverse reaction to magnesium sulfate. Magnesium sulfate can cause respiratory depression at higher doses, but a respiratory rate of 16/min does not raise immediate concerns.
Correct Answer is D
Explanation
Choice A rationale:
Levothyroxine is not a medication used to treat gestational diabetes mellitus. Levothyroxine is a synthetic thyroid hormone used to treat hypothyroidism, which is a different medical condition.
Choice B rationale:
Nifedipine is a calcium channel blocker primarily used to manage hypertension and angina. It is not indicated for the treatment of gestational diabetes mellitus.
Choice C rationale:
Chlorpromazine is an antipsychotic medication used to treat conditions like schizophrenia and bipolar disorder. It has no role in the treatment of gestational diabetes mellitus.
Choice D rationale:
Glyburide is the correct medication to expect for administering to a client with gestational diabetes mellitus. Glyburide is an oral antidiabetic agent that helps lower blood glucose levels by increasing insulin secretion from the pancreas. It is often used when dietary and lifestyle modifications are not sufficient in managing gestational diabetes. However, it is essential to follow healthcare provider guidelines and closely monitor the client's blood glucose levels while on this medication. In some cases, insulin may be required if glyburide alone is inadequate in controlling blood sugar levels.
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