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

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.

A. “My baby will be placed under special lights if the test is elevated.”. B. “Sometimes the test is repeated in the doctor’s office at the 2-week check-up.”. C. “My baby must take formula or breast milk before the test is done.”. D. “This test checks for a genetic disorder that can be corrected by diet.”.

Correct Answer is A

Explanation

Choice A rationale

The statement “My baby will be placed under special lights if the test is elevated” indicates a need for further teaching. This statement is incorrect because phototherapy (special lights) is not used to treat phenylketonuria (PKU). PKU is a genetic disorder that results in the body’s inability to metabolize the amino acid phenylalanine. If left untreated, it can lead to intellectual disability and other serious health problems. The treatment for PKU involves a special diet that is low in phenylalanine. Therefore, the parent’s statement about using special lights for treatment indicates a misunderstanding about the nature of PKU and its treatment.

Choice B rationale

The statement “Sometimes the test is repeated in the doctor’s office at the 2-week check-up” is correct. PKU is usually diagnosed through a routine newborn screening test, and if the initial test results are positive or unclear, the test may be repeated.

Choice C rationale

The statement “My baby must take formula or breast milk before the test is done” is correct. For accurate results, the PKU test is done after the baby is 24 hours old and after the baby has had some protein in the diet.

Choice D rationale

The statement “This test checks for a genetic disorder that can be corrected by diet” is correct. PKU is a genetic disorder that can be managed with a special diet low in phenylalanine.

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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 caring for an infant who has spina bifida.Which of the following actions should the nurse take?

Correct Answer is B

Explanation

A nurse is reinforcing teaching about phenylketonuria (PKU) testing with the parent of a newborn.Which of the following statements by the parent indicates a need for further teaching?

Correct Answer is A

Explanation

A nurse is collecting data from an infant who has developmental dysplasia of the hip (DDH). Which of the following findings should the nurse expect?

A nurse is caring for a toddler who is scheduled to have a lumbar puncture.Which of the following actions should the nurse take?

A nurse is updating the plan of care for a newborn who is undergoing phototherapy.Which of the following actions should the nurse include in the plan?

A nurse is assisting with the care of a child who has spina bifida.Which of the following precautions should the nurse take while caring for this child?

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A nurse is contributing to the plan of care for a 2-month-old infant who has just undergone cleft palate repair.Which of the following interventions should the nurse contribute to the client’s plan of care?

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.