An 18-hour-old baby with an elevated bilirubin level is placed under the bili lights.
Which of the following is an expected nursing action in these circumstances?
Give the baby oral rehydration therapy in place of all feedings.
Rotate the baby from side to back to side to front every 2 hours.
Apply restraints to keep the baby under the light source.
Administer intravenous fluids via pump per doctor orders.
The Correct Answer is B
Choice A rationale
Oral rehydration therapy is not used in place of feedings for infants undergoing phototherapy for elevated bilirubin levels. It's crucial to maintain proper nutrition and hydration through regular feedings.
Choice B rationale
Rotating the baby helps ensure even exposure to the bili lights, which aids in breaking down bilirubin effectively across the baby's body.
Choice C rationale
Applying restraints is inappropriate and unnecessary. It could cause distress and is not a standard practice for phototherapy.
Choice D rationale
Administering intravenous fluids is not typically needed unless there's a risk of dehydration or other medical indications as per the doctor's orders.
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Correct Answer is B
Explanation
Choice A rationale
Applying ice packs can help reduce pain and swelling, but it is not the best intervention for a breastfeeding mother with mastitis. Ice can constrict blood vessels and may hinder milk
flow, which can exacerbate the condition.
Choice B rationale
Frequent breastfeeding helps to empty the affected breast and prevent milk stasis, reducing the risk of abscess formation and promoting faster healing. The mechanical action of
nursing can help clear the infection and provide relief.
Choice C rationale
Weaning immediately is not advised as it can lead to engorgement and milk stasis, worsening the infection. Continuing to breastfeed ensures the breast is regularly emptied, aiding
in recovery.
Choice D rationale
While notifying the pediatrician may be necessary if the baby is affected, it does not directly address the mother's condition or provide immediate relief. Primary management focuses
on treating the infection and maintaining milk flow.
Correct Answer is A
Explanation
Choice A rationale
Assessing for vaginal bleeding in PPROM is generally not necessary unless there is an indication of placental issues or other complications. PPROM involves the rupture of
membranes before 37 weeks, primarily requiring monitoring for infection and fetal wellbeing rather than routine bleeding checks.
Choice B rationale
Monitoring for signs of infection is critical after PPROM because the rupture increases the risk of ascending infections. The nurse should diligently assess for fever, foul-smelling
discharge, and other signs of infection to initiate timely interventions, preserving both maternal and fetal health.
Choice C rationale
Checking for cervical dilation in PPROM is important because premature rupture of membranes can lead to preterm labor. Monitoring dilation helps determine if labor is imminent,
influencing decisions regarding maternal and neonatal care to prevent complications from premature birth.
Choice D rationale
Watching for fetal compromise is necessary following PPROM as premature rupture of membranes can lead to umbilical cord compression or other complications affecting fetal oxygenation. Continuous fetal monitoring helps detect early signs of distress, allowing timely intervention to ensure fetal safety.