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
Swaddling provides warmth but doesn't address jitteriness, which may be due to hypoglycemia.
Choice B rationale
Jitteriness in a newborn can indicate hypoglycemia. Prompt glucose assessment is crucial for early detection and management.
Choice C rationale
Feeding could help with glucose levels, but without knowing the glucose status, it might not be the immediate priority.
Choice D rationale
Routine medications are important but not as urgent as addressing possible hypoglycemia in a jittery baby.
Correct Answer is C
Explanation
Choice A rationale
Decreased pain level can be an effect of addressing the cause of pain, but it doesn't indicate improved uterine tone or resolution of atony.
Choice B rationale
Stable blood pressure is important, but it is not the direct outcome of improved uterine tone or the resolution of uterine atony.
Choice C rationale
A firm fundus at or below the umbilicus indicates successful contraction of the uterus, resolving uterine atony and reducing bleeding.
Choice D rationale
Reduced lochial flow can indicate decreased bleeding, but it does not directly indicate improved uterine tone or resolution of uterine atony.