The nurse is preparing a 4-day-old client 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?

Reference Range:

Total Bilirubin [0.1 to 10.5 mg/dL (17.1 to 180 μmol/L)]

Reposition the infant every 2 hours.

Feed the infant every 4 hours.

Cover with a receiving blanket.

Perform diaper changes under the light.

Answer and Explanation

The Correct Answer is A

A. This is the correct instruction. Repositioning the infant every 2 hours during phototherapy ensures that light exposure is distributed evenly over the skin surface, maximizing bilirubin breakdown. Proper rotation is essential to effective home phototherapy.

B. Feeding every 4 hours is insufficient for a newborn undergoing phototherapy. Frequent feedings (every 2–3 hours) help maintain hydration and promote bilirubin excretion through stool and urine. Therefore, this recommendation is unsafe and not appropriate for discharge teaching.

C. The infant’s eyes should be covered for protection during phototherapy, but covering the entire body with a receiving blanket is contraindicated. Covering the infant blocks therapeutic light exposure and reduces the effectiveness of phototherapy.

D. Diaper changes should be done as needed to maintain hygiene, but performing them specifically under the light is not required. The priority is to maintain consistent light exposure for the rest of the body while protecting the eyes and genital area.

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Correct Answer is A

Explanation

A. This is the most effective and evidence-based approach. Starting with less sensitive questions helps build rapport, establish trust, and make the client feel safe before addressing more personal or potentially traumatic topics such as domestic violence. Gradually increasing the sensitivity of questions allows the client to respond more comfortably and reduces the risk of retraumatization.

B. Asking vague or non-specific questions may confuse the client and result in incomplete or inaccurate information. Clear, specific, and open-ended questions are essential for accurate assessment.

C. Sharing personal values is inappropriate in a professional healthcare setting. It can shift focus away from the client and may influence or bias the client’s responses. The nurse’s role is to remain objective and supportive.

D. Asking the most difficult questions first can intimidate or distress the client, potentially causing them to withhold information or disengage from the interview. A gradual, sensitive approach is recommended for topics like suspected abuse.

A. Make certain a family member knows the name and use of all medications currently being taken. B. Do not take any over-the-counter (OTC) drugs while taking medications prescribed by a healthcare provider. C. Use a medication reminder system to prevent omitting to take the right medications at the right time. D. Bring all medications, supplements, and herbs currently being taken to the next clinic appointment.

Correct Answer is D

Explanation

A. While it is helpful for family members to be aware of a client’s medications, this does not address the potential duplication of prescriptions or the need for a healthcare provider to review the actual list. It is a supportive measure rather than a corrective one.

B. Avoiding OTC drugs is important to prevent interactions, but this instruction alone does not address the immediate concern of duplicate prescriptions, which can cause toxicity or adverse effects.

C. Using a medication reminder system helps with adherence but does not solve the problem of taking multiple medications for the same indication, which can be harmful.

D. This is the most effective instruction. Bringing all medications, including prescriptions, supplements, and herbs, to the next clinic visit allows the healthcare provider to review the list for duplications, interactions, or unnecessary medications. This practice, often called “brown bag review,” ensures safe medication management, reduces the risk of adverse effects, and provides an opportunity for patient education regarding correct use.

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Naxlex Comprehensive Predictor Exams

A client presents to the emergency department (ED) reporting abdominal pain. The nurse observes the client's right cheek and eye are bruised and suspects possible domestic violence. Which approach is best for the nurse to use when interviewing the client?

Correct Answer is A

Explanation

Correct Answer is D

Explanation

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Complete the diagram by dragging from the choices area to specify which condition the client is most likely experiencing, two actions the nurse should take to address that condition, and two parameters the nurse should monitor to assess the client's progress.

The nurse is caring for a client who is having trouble breastfeeding. Which action by the nurse is the most helpful?

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