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 C
Explanation
Choice A rationale
Administering NSAIDs every 4 to 6 hours is not a primary measure to prevent thrombophlebitis. NSAIDs are used for pain relief and inflammation reduction, but they do not directly prevent blood clots.
Choice B rationale
Applying elastic stockings before the client gets out of bed can help prevent blood clots by promoting blood flow in the legs. However, this measure alone is not sufficient to prevent thrombophlebitis.
Choice C rationale
Ambulation, or walking, is one of the most effective measures to prevent thrombophlebitis. It promotes circulation and prevents blood from pooling in the legs, reducing the risk of clot formation.
Choice D rationale
Applying warm, moist packs to the client’s lower legs can help relieve pain and inflammation but does not directly prevent thrombophlebitis. This measure is more supportive rather than preventive.
Correct Answer is A
Explanation
Choice A rationale
A positive Babinski reflex is characterized by the fanning out of the toes and the upward movement of the big toe when the sole of the foot is stroked. This reflex is normal in infants up to 2 years old and indicates an immature central nervous system. The presence of this reflex in older children or adults can indicate neurological issues.
Choice B rationale
Curling in of the toes when the sole of the foot is stroked is indicative of the plantar grasp reflex, not the Babinski reflex. The plantar grasp reflex is a different neurological response and does not indicate the same neurological development as the Babinski reflex.
Choice C rationale
No response when the sole of the foot is stroked could indicate a lack of neurological response or an issue with the sensory or motor pathways. This is not characteristic of a positive Babinski reflex and could be a sign of neurological impairment.
Choice D rationale
The big toe bending down when the sole of the foot is stroked is a normal response in older children and adults, known as the plantar reflex. This response indicates a mature central nervous system and is not characteristic of a positive Babinski reflex in infants.