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.
Free Nursing Test Bank
- Free Pharmacology Quiz 1
- Free Medical-Surgical Quiz 2
- Free Fundamentals Quiz 3
- Free Maternal-Newborn Quiz 4
- Free Anatomy and Physiology Quiz 5
- Free Obstetrics and Pediatrics Quiz 6
- Free Fluid and Electrolytes Quiz 7
- Free Community Health Quiz 8
- Free Promoting Health across the Lifespan Quiz 9
- Free Multidimensional Care Quiz 10
View Related questions
Correct Answer is D
Explanation
Choice A rationale
Amniotic fluid with meconium noted can indicate fetal distress, but it is not the most immediate priority compared to fetal heart tones.
Choice B rationale
A maternal temperature of 38.3°C (101°F) can indicate infection, but it is not the most immediate priority compared to fetal heart tones.
Choice C rationale
Foul-smelling vaginal discharge can indicate infection, but it is not the most immediate priority compared to fetal heart tones.
Choice D rationale
Fetal heart tones of 98/min indicate fetal bradycardia, which is a sign of fetal distress and requires immediate intervention to ensure the well-being of the fetus.
Correct Answer is ["E","F"]
Explanation
Choice A rationale:
The head assessment finding is not mentioned as abnormal in the exhibits. The anterior fontanelle is soft and flat, which is a normal finding in newborns. This indicates that there is no increased intracranial pressure or dehydration. The head circumference and shape are also not noted to have any abnormalities, which suggests that the newborn’s head development is within normal limits.
Choice B rationale:
The glucose level is not provided in the exhibits. However, routine glucose monitoring is not typically required for healthy, term newborns unless they exhibit symptoms of hypoglycemia or have risk factors such as being large for gestational age, small for gestational age, or born to mothers with diabetes. Since the newborn is feeding well and has no signs of hypoglycemia, there is no immediate concern regarding glucose levels.
Choice C rationale:
The mucous membrane assessment shows that the mucous membranes are moist and pink, which is a normal finding. This indicates that the newborn is well-hydrated and has good perfusion. There are no signs of dehydration, pallor, or lesions in the oral cavity, which suggests that the newborn’s mucous membranes are healthy.
Choice D rationale:
The intake and output are adequate, as evidenced by the number of wet diapers and stools. The newborn has had six wet diapers and three stools in the past 24 hours, which is within the normal range for a healthy, breastfed newborn. This indicates that the newborn is receiving sufficient nutrition and is well-hydrated.
Choice E rationale:
The respiratory rate of 44/min is on the higher end of the normal range for newborns, which is typically 30-60 breaths per minute. However, it is important to monitor for any signs of respiratory distress or abnormalities, such as grunting, flaring, or retractions. Reporting this finding ensures that any potential issues are addressed promptly.
Choice F rationale:
The heart rate of 154/min is within the normal range for newborns, which is typically 120-160 beats per minute. However, it is on the higher end of the spectrum. Monitoring and reporting this finding is crucial to ensure that the newborn’s cardiovascular status remains stable and to rule out any underlying conditions that may require intervention.