A nurse is contributing to the plan of care for a newborn who has a new prescription for phototherapy with a lamp.Which of the following interventions should the nurse recommend?
Apply lotion to the newborn’s extremities every 8 hours.
Reposition the newborn every 4 hours.
Remove the eye mask during feedings.
Supplement feedings with glucose water.
The Correct Answer is C
Choice A rationale
Applying lotion to the newborn’s extremities every 8 hours is not recommended during phototherapy. Lotions and ointments can cause burns when exposed to phototherapy lights and may interfere with the treatment’s effectiveness.
Choice B rationale
Repositioning the newborn every 4 hours is not frequent enough. The newborn should be repositioned every 2 hours to ensure even exposure to the phototherapy light and to prevent pressure sores.
Choice C rationale
Removing the eye mask during feedings is correct. The eye mask should be removed during feedings to allow for bonding and to check for any signs of irritation or infection. This also ensures that the newborn’s eyes are protected from the phototherapy light when not under the lamp.
Choice D rationale
Supplementing feedings with glucose water is not recommended. Breast milk or formula should be used to ensure the newborn receives adequate nutrition and hydration. Glucose water does not provide the necessary nutrients and can interfere with breastfeeding.
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Correct Answer is B
Explanation
Choice A rationale
The statement about the partner wanting to help but not planning for the baby indicates a lack of acceptance and preparation for the pregnancy. It suggests that the adolescent and their partner may not have fully embraced the reality of the pregnancy.
Choice B rationale
Missing soda but acknowledging that it is better for the baby indicates that the adolescent is making sacrifices and changes for the benefit of the baby. This behavior reflects acceptance of the pregnancy and a willingness to prioritize the baby’s health.
Choice C rationale
Being upset about having to quit school when the baby comes indicates that the adolescent is struggling with the impact of the pregnancy on their life plans. This statement suggests a lack of acceptance and difficulty in adjusting to the pregnancy.
Choice D rationale
Expecting the parents to raise the baby due to being young indicates a lack of acceptance and responsibility for the pregnancy. It suggests that the adolescent may not be fully prepared to take on the role of a parent.
Correct Answer is C
Explanation
Choice A rationale
Nursing the baby for 5 to 10 minutes on each breast may not be sufficient for the baby to receive the hindmilk, which is rich in fat and essential for growth.
Choice B rationale
Applying vitamin E oil to the nipples after each feeding is not recommended as it can cause irritation and is not necessary for nipple care.
Choice C rationale
Laying the baby on a pillow at the level of the breast helps ensure proper positioning and latch, which is crucial for effective breastfeeding and preventing nipple soreness.
Choice D rationale
Ensuring that just the nipple is in the baby’s mouth is incorrect. The baby should latch onto the areola, not just the nipple, to ensure effective milk transfer and prevent nipple pain.