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 A
Explanation
Choice A rationale
Checking the identity of individuals who come to remove the baby from the room is crucial for preventing infant abduction and ensuring the safety of the newborn.
Choice B rationale
Matching the bracelet on the baby with the footprint record each shift is not a standard practice for newborn identification and safety.
Choice C rationale
Scanning the baby’s identification bracelet each time they are checked on is not a common practice and may not be feasible.
Choice D rationale
Wearing an electronic bracelet when out of the room is a safety measure, but it does not replace the need for parents to verify the identity of individuals handling their baby.
Correct Answer is D
Explanation
Choice A rationale
A temperature of 37.8°C (100°F) 18 hours postpartum is slightly elevated but not necessarily indicative of a serious issue. It may require monitoring but is not the most urgent concern.
Choice B rationale
Abdominal pain during breastfeeding 8 hours postpartum is a common experience due to uterine contractions. While it may cause discomfort, it is not typically an urgent concern.
Choice C rationale
Not having a bowel movement 24 hours postpartum is not uncommon and does not usually require immediate attention. It can be addressed with dietary changes and other interventions.
Choice D rationale
Saturating one perineal pad over 2 hours 6 hours postpartum in a G5P4 client indicates a potential risk of postpartum hemorrhage. This is a more urgent concern that requires immediate assessment and intervention to prevent complications.