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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
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.
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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