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A nurse is caring for a newborn with hyperbilirubinemia and is being treated with phototherapy.
For each of the following nursing actions, specify if it is indicated or contraindicated with phototherapy treatment.

A.

Apply lotion to the skin every 4 hours.

B.

Remove the newborn from phototherapy every 4 hours for thorough assessment of adverse effects of phototherapy.

C.

Newborn feedings should be every 8 hours.

D.

Maintain an eye mask over the newborn's eyes.

Question Solution

Correct Answer : A,B,C,D,E,F

B. Remove the newborn from phototherapy every 4 hours for thorough assessment of adverse effects of phototherapy.

D. Maintain an eye mask over the newborn's eyes.

E. Reposition the newborn every 2 hours.

F. Report sunken fontanels to the provider. Contraindicated:

A. Apply lotion to the skin every 4 hours.

C. Newborn feedings should be every 8 hours.


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Correct Answer is D

Explanation

Choice A rationale

Elevated WBC count is not typically associated with HELLP syndrome. HELLP syndrome involves hemolysis, elevated liver enzymes, and low platelet count.

Choice B rationale

Elevated platelet count is not a feature of HELLP syndrome. In fact, thrombocytopenia (low platelet count) is a hallmark of the condition.

Choice C rationale

Decreased BUN is not a characteristic of HELLP syndrome. The syndrome primarily affects liver function and platelets.

Choice D rationale

Elevated liver enzymes are a key diagnostic feature of HELLP syndrome, reflecting liver dysfunction and damage, which is part of the condition's pathology. .

Correct Answer is D

Explanation

Choice A rationale

Administering the rubella vaccine during pregnancy, including the third trimester, is contraindicated due to the risk of live vaccine transmission to the fetus. It is not recommended at any stage of pregnancy.

Choice B rationale

Advising the client to get the vaccine during her next pregnancy attempt is partly correct but lacks the immediacy needed to ensure she is immune before the next pregnancy. The vaccine should be given postpartum.

Choice C rationale

Administering the vaccine immediately during pregnancy is contraindicated due to potential risks to the fetus. Rubella vaccines contain live virus, which can cause fetal harm if given during pregnancy.

Choice D rationale

It is safest to administer the rubella vaccine postpartum, prior to hospital discharge, to ensure the client has immunity before any future pregnancies. This timing prevents any risk to the current fetus and ensures future fetal protection. .

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