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 D

Explanation

Choice A rationale

The carotid pulse is not the most reliable location to check an infant’s pulse because it can be difficult to locate and can cause discomfort to the infant.

Choice B rationale

The dorsalis pedis pulse is not the most reliable location to check an infant’s pulse because it can be difficult to locate in small infants.

Choice C rationale

The temporal pulse is not the most reliable location to check an infant’s pulse because it can be affected by external factors such as temperature and can be difficult to locate in small infants.

Choice D rationale

The apical pulse is the most reliable location to check an infant’s pulse. It is located at the apex of the heart and can be easily heard using a stethoscope. It provides the most accurate assessment of the heart rate.

A. Mix the medication with 10 mL of formula. B. Measure the elixir in a medicine cup before transferring to a syringe. C. Position the syringe to the side of the infant’s tongue. D. Place the infant supine in a crib prior to administration.

Correct Answer is C

Explanation

The correct answer is C. When administering an oral elixir to a 3-month-old infant using an oral medication syringe, the nurse should position the syringe to the side of the infant’s tongue. This prevents the medication from being administered too quickly and reduces the risk of choking.

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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.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is collecting data from an infant.Which of the following sites is the most reliable location to check the infant’s pulse?

Correct Answer is D

Explanation

A nurse is preparing to administer an oral elixir to a 3-month-old infant using an oral medication syringe. Which of the following actions should the nurse take?

Correct Answer is C

Explanation

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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.