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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?

A.

Give the baby oral rehydration therapy in place of all feedings.

B.

Rotate the baby from side to back to side to front every 2 hours.

C.

Apply restraints to keep the baby under the light source.

D.

Administer intravenous fluids via pump per doctor orders.

Answer and Explanation

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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View Related questions

Correct Answer is D

Explanation

Choice A rationale

Reflexes of 3+ indicate hyperreflexia, common in pre-eclampsia, but not necessarily critical. Monitoring is essential but not an emergency.

Choice B rationale

Urinary output of 30 mL/hr is within the acceptable range but requires monitoring for any changes. It's not a critical alert.

Choice C rationale

A respiratory rate of 16 rpm is normal and does not indicate immediate risk requiring physician notification.

Choice D rationale

Serum magnesium level of 10 mg/dL is significantly high, indicating potential toxicity. Immediate physician notification is critical to adjust magnesium sulfate administration.

Correct Answer is D

Explanation

Choice A rationale

Checking blood sugar is important in gestational diabetes but isn't immediate priority in a triage setting compared to assessing urgent conditions that could harm the fetus or mother immediately.

Choice B rationale

Assessing vaginal blood loss post-abortion is crucial, but in the presence of ruptured membranes, fetal heart rate checks take precedence to ensure the fetus's immediate well-being.

Choice C rationale

Assessing patellar reflexes in pre-eclampsia management is significant, but immediate priority in labor and delivery triage goes to ensuring fetal safety after membrane rupture.

Choice D rationale

Checking the fetal heart rate after membrane rupture is a priority because it provides immediate information about the fetus's status and any potential complications like cord prolapse or distress.

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