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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 ["A","B","C","D","E"]

Explanation

Choice A rationale

Postpartum blues typically resolve within the first two weeks postpartum and involve mild symptoms like mood swings and irritability. In contrast, postpartum depression can persist

longer and requires treatment.

Choice B rationale

Symptoms of postpartum blues usually disappear without medical intervention, whereas postpartum depression often needs professional treatment to manage the more severe and

persistent symptoms.

Choice C rationale

Postpartum depression can impair a mother's ability to care for herself and her baby safely, requiring intervention to prevent harm. Postpartum blues do not typically cause such severe

functional impairment.

Choice D rationale

Postpartum depression may require antidepressants for treatment due to its severity. Postpartum blues generally do not necessitate such interventions and are managed through

support and reassurance.

Choice E rationale

Postpartum depression can occur at any time within the first 12 months after delivery, while postpartum blues are usually confined to the initial two weeks postpartum.

Correct Answer is C

Explanation

Choice A rationale

Assessing the client's blood pressure can help determine if there is a significant loss of blood and consequent hypotension. However, it is not the immediate first action to manage

heavy bleeding postpartum.

Choice B rationale

Assessing the bladder for distention is crucial as a full bladder can interfere with uterine contraction, potentially leading to increased bleeding. But, it isn't the first priority compared to

addressing the immediate bleeding.

Choice C rationale

Massaging the client's fundus is the priority action in this case. It helps to contract the uterus, thereby reducing bleeding. Uterine atony is the most common cause of postpartum

hemorrhage, and fundal massage is the first intervention to manage it.

Choice D rationale

Preparing to administer a prescription may be necessary, especially if uterotonics are required. However, this is a subsequent step after attempting to control the bleeding through

fundal massage.

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