The nurse is preparing to care for a newborn receiving phototherapy.
Which interventions should be included in the plan of care? Select all that apply.

Avoid stimulation.

Decrease fluid intake.

Monitor skin temperature closely.

Cover the newborn’s eyes with eye shields or patches.

Reposition the newborn every 2 hours.

Answer and Explanation

Correct Answer : C,D,E

Choice A rationale

Avoiding stimulation is not a necessary intervention for a newborn receiving phototherapy. Phototherapy is a treatment for jaundice where the exposure of skin to a light source converts unconjugated bilirubin molecules into water-soluble isomers that can be excreted by the usual pathways. There is no specific need to avoid stimulation during this treatment.

Choice B rationale

Decreasing fluid intake is not a recommended intervention for a newborn receiving phototherapy. In fact, adequate hydration is important during phototherapy to promote the excretion of bilirubin. Therefore, fluid intake should not be decreased.

Choice C rationale

Monitoring skin temperature closely is a necessary intervention for a newborn receiving phototherapy. The lights used in phototherapy can generate heat, so it’s important to monitor the baby’s temperature to prevent overheating.

Choice D rationale

Covering the newborn’s eyes with eye shields or patches is a necessary intervention during phototherapy. This is done to protect the baby’s eyes from the bright lights used in the treatment.

Choice E rationale

Repositioning the newborn every 2 hours is a necessary intervention during phototherapy. This helps to expose different areas of the baby’s skin to the light, which can improve the effectiveness of the treatment.

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Correct Answer is ["B","C","D","E"]

Explanation

Choice A rationale

Pursed lips are not typically a sign of pain in an infant.

Choice B rationale

Pushing away stimuli can be a sign that an infant is in pain.

Choice C rationale

A loud cry can be a sign of pain in an infant.

Choice D rationale

A rigid body can be a sign of pain in an infant.

Choice E rationale

Furrowed eyebrows can be a sign of pain in an infant.

A. Feed the infant through an NG tube. B. Place the infant in a prone position. C. Cover the infant’s lesion with a dry cloth. D. Perform range-of-motion (ROM) exercises to the infant’s hips.

Correct Answer is B

Explanation

Choice A rationale

Feeding an infant with spina bifida through an NG tube may not be necessary unless the child has specific feeding difficulties or other health issues. Spina bifida does not typically affect a child’s ability to eat or swallow.

Choice B rationale

Placing an infant with spina bifida in a prone position can help protect and care for the lesion on their back. It can also help prevent pressure sores and promote comfort.

Choice C rationale

Covering the infant’s lesion with a dry cloth is not typically recommended. The lesion should be kept clean and moist to promote healing and prevent infection.

Choice D rationale

While physical therapy and exercises can be beneficial for children with spina bifida, performing range-of-motion exercises to the infant’s hips may not be necessary unless specifically recommended by a healthcare provider.

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The nurse is preparing to care for a newborn receiving phototherapy.Which interventions should be included in the plan of care? Select all that apply.

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The nurse is preparing to care for a newborn receiving phototherapy.
Which interventions should be included in the plan of care? Select all that apply.