The nurse is preparing a 4-day-old infant with a serum bilirubin level of 19 mg/dL (325 µmol/L) for discharge from the hospital. When teaching the parents about home phototherapy, which instruction should the nurse include in the discharge teaching plan?
Total Bilirubin Reference Range: Newborn: 0.1 to 10.5 mg/dL (1.7 to 180 µmol/L)
Feed the infant every 4 hours.
Perform diaper changes under the light.
Reposition the infant every 2 hours.
Cover with a receiving blanket.
The Correct Answer is C
Choice A reason: Feeding the infant every 4 hours is not a specific instruction for home phototherapy, which is a treatment that uses blue light to break down excess bilirubin in the skin and blood. However, feeding the infant frequently is important to promote hydration and elimination of bilirubin through urine and stool.
Choice B reason: Performing diaper changes under the light is not a recommended instruction for home phototherapy, which is a treatment that uses blue light to break down excess bilirubin in the skin and blood. The nurse should instruct the parents to turn off the light and cover the infant's eyes with protective goggles or patches during diaper changes to prevent eye damage or irritation.
Choice C reason: This is the correct answer because repositioning the infant every 2 hours is an essential instruction for home phototherapy, which is a treatment that uses blue light to break down excess bilirubin in the skin and blood. The nurse should instruct the parents to rotate the infant's position every 2 hours to expose different areas of the skin to the light and prevent pressure ulcers or skin breakdown.
Choice D reason: Covering with a receiving blanket is not an appropriate instruction for home phototherapy, which is a treatment that uses blue light to break down excess bilirubin in the skin and blood. The nurse should instruct the parents to keep the infant unclothed except for a diaper and eye protection during phototherapy to maximize skin exposure to the light and increase its effectiveness.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A reason: This is the correct answer because a distended bladder can cause uterine displacement and interfere with uterine contraction, leading to increased bleeding and risk of infection. The nurse should check for bladder fullness and encourage the client to void or catheterize if necessary.
Choice B reason: Reviewing the hemoglobin to determine hemorrhage is an important action, but not the first one. The nurse should first identify and correct the cause of bleeding, such as bladder distension or uterine atony, before checking for blood loss and anemia.
Choice C reason: Massaging the uterus to decrease atony is not indicated in this case, because the uterus is already firm. Massaging a firm uterus can cause overstimulation and pain.
Choice D reason: Increasing intravenous infusion is not the first action, because it may worsen bleeding by increasing blood pressure and diluting clotting factors. The nurse should first assess and manage bleeding before administering fluids or blood products as prescribed.
Correct Answer is A
Explanation
Choice A reason: This is correct because a firm mattress reduces the risk of suffocation and rebreathing of carbon dioxide, which are associated with SIDS.
Choice B reason: This is incorrect because propping the infant with a pillow can cause the infant to slide down and suffocate or obstruct the airway.
Choice C reason: This is incorrect because swaddling the infant in a blanket can cause overheating, which is a risk factor for SIDS.
Choice D reason: This is incorrect because placing the infant in a prone position can increase the risk of SIDS by impairing gas exchange and thermoregulation.
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