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A nurse is planning care for a newborn who is scheduled to start phototherapy using a lamp. Which of the following actions should the nurse include in the plan?
- A. Apply a thin layer of lotion to the newborn skin every 8 hrs.
- B. Give the newborn 1oz of glucose water every 4 hrs
- C. Ensure the newborn eyes are closed beneath the shield.
- D. Dress the newborn in a thin layer of clothing during therapy
Correct Answer: C
Rationale: Rationale: Choice C is correct because ensuring the newborn's eyes are closed beneath the shield during phototherapy prevents potential eye damage from the bright light. Closing the eyes protects the delicate eye tissues from exposure to the intense light. This action is crucial in preventing eye injury and promoting the safety and well-being of the newborn.
Incorrect Choices:
A: Applying lotion to the skin can intensify the effects of the light and should be avoided.
B: Giving glucose water is unnecessary and not related to phototherapy.
D: Dressing the newborn in clothing can interfere with the effectiveness of the light therapy.
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A nurse is reviewing the laboratory results of a newborn. Which of the following findings should the nurse report to the provider?
- A. Blood glucose 58 mg/dL
- B. Hematocrit 48%
- C. Platelets 100,000/mm³
- D. Hemoglobin 16 g/dL
Correct Answer: C
Rationale: The correct answer is C: Platelets 100,000/mm³. This finding should be reported as it indicates a low platelet count, which can lead to bleeding issues in the newborn. A normal platelet count in a newborn is typically higher than 150,000/mm³. Low platelets can increase the risk of bleeding, especially in the setting of birth trauma.
A: Blood glucose 58 mg/dL is within the normal range for a newborn.
B: Hematocrit 48% is within the normal range for a newborn.
D: Hemoglobin 16 g/dL is within the normal range for a newborn.
In summary, the correct answer is C because it signifies a potential health concern for the newborn, while the other options fall within normal ranges and do not require immediate medical attention.
A nurse is planning care for a newborn who is scheduled to start phototherapy using a lap.
- A. Apply a thin layer lotion to the newborn's skin every 8 hours
- B. Dress the newborn in a thin layer of clothing during the therapy
- C. Ensure the newborn's eyes are closed beneath the shield
- D. Give the newborn 1 oz of glucose water every 4 hours
Correct Answer: C
Rationale: The correct answer is C: Ensure the newborn's eyes are closed beneath the shield. During phototherapy, the newborn's eyes need to be protected from the bright lights to prevent potential eye damage. Closing the eyes beneath the shield helps to shield them from the light exposure. This step is crucial in preventing complications and ensuring the safety and well-being of the newborn.
Other choices are incorrect because:
A: Applying lotion to the newborn's skin may interfere with the effectiveness of the phototherapy and is not necessary for the treatment.
B: Dressing the newborn in clothing may also interfere with the effectiveness of the phototherapy as the light needs direct contact with the skin.
D: Giving glucose water every 4 hours is not indicated for phototherapy and may not be appropriate for the newborn's condition.
In summary, ensuring the newborn's eyes are closed beneath the shield is the correct choice as it is essential for the safety and effectiveness of the phototherapy treatment.
A nurse is providing discharge teaching to a postpartum client about caring for her five-day-old male newborn at home.
- A. Retract the foreskin to clean your baby's penis during each bath
- B. Use triple antibiotic ointment on your baby's umbilical cord twice per day
- C. Swaddle your baby tightly with legs extended before laying him down to sleep
- D. Notify your baby's pediatrician if he urinates less than 6 times per day
Correct Answer: D
Rationale: The correct answer is D: Notify your baby's pediatrician if he urinates less than 6 times per day. This is important because adequate urine output is a sign of good hydration and kidney function in newborns. Notifying the pediatrician if the baby urinates less than 6 times a day can help identify any potential issues early on.
Choice A is incorrect because retracting the foreskin to clean the baby's penis is not recommended as it can lead to infections.
Choice B is incorrect because using triple antibiotic ointment on the umbilical cord is not necessary and can actually delay healing.
Choice C is incorrect because swaddling the baby tightly with legs extended can increase the risk of hip dysplasia.
Overall, it is important to focus on monitoring the baby's urine output and notifying the pediatrician if there are any concerns.
A nurse on a labor and delivery unit is receiving infection control standards with a newly licensed nurse. The nurse should instruct the newly licensed nurse to don gloves for which of the following procedures?
- A. Assisting a mother with breastfeeding
- B. Performing a newborn’s initial bath
- C. Administering the measles, mumps, rubella vaccine
- D. Performing umbilical cord care
Correct Answer: D
Rationale: The correct answer is D: Performing umbilical cord care. Gloves should be worn when performing this procedure to prevent potential infection transmission. The umbilical cord stump is a point of entry for pathogens, making it important to maintain strict infection control. Assisting a mother with breastfeeding (A) does not require gloves unless there are open wounds or sores on the mother's breast. Performing a newborn’s initial bath (B) does not necessitate gloves unless there are specific concerns like skin conditions. Administering the measles, mumps, rubella vaccine (C) typically requires clean, not sterile, technique. In summary, wearing gloves during umbilical cord care is essential to prevent infection transmission, making it the correct choice in this scenario.
A nurse is caring for a client who is receiving oxytocin to induce labor. The nurse should discontinue the oxytocin if which of the following occurs?
- A. Contractions last 60 seconds
- B. Non-repetitive early decelerations
- C. 6 contractions in 10 minutes
- D. Moderate variability of the fetal heart rate
Correct Answer: A
Rationale: The correct answer is A: Contractions last 60 seconds. Prolonged contractions can lead to uterine hyperstimulation, which can decrease oxygen supply to the fetus, posing a risk of fetal distress. Discontinuing oxytocin in this situation is crucial to prevent further complications.
B: Non-repetitive early decelerations are not directly related to oxytocin administration and do not warrant discontinuation of the medication.
C: 6 contractions in 10 minutes is a sign of uterine hyperstimulation but alone may not be enough to discontinue oxytocin.
D: Moderate variability of the fetal heart rate is a reassuring sign of fetal well-being, not an indication to discontinue oxytocin.