Nokea
The home health nurse is educating parents on home phototherapy. What will the nurse include when providing information to these parents?
- A. Cover the infant's eyes when under the light.
- B. Use a three-prong plug.
- C. Keep a diaper in place.
- D. Place the light source on an absorbent surface.
- E. Expose as much skin as possible.
Correct Answer: B,C,E
Rationale: Home phototherapy instructions include using a three-prong plug, keeping a diaper in place, and exposing as much skin as possible; the light source should be on a nonabsorbent surface, and eyes do not need covering.
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What is the nurse's best response?
- A. The light increases the infant's metabolism.'
- B. The light stimulates liver function.'
- C. The light dilates blood vessels.'
- D. The light breaks down bilirubin.'
Correct Answer: D
Rationale: Phototherapy breaks down excess bilirubin to prevent kernicterus, allowing it to be excreted.
What nursing action will the nurse implement after feeding an infant with hydrocephalus?
- A. Position the infant sitting upright in an infant seat.
- B. Place the infant over the shoulder to burp.
- C. Leave the infant in a side-lying position.
- D. Stimulate the infant by rubbing its feet.
Correct Answer: C
Rationale: Children with hydrocephalus are prone to vomiting; a side-lying position in a quiet atmosphere after feeding reduces the incidence of vomiting.
What body system has the highest risk of congenital anomaly in a child with Down syndrome?
- A. Reproductive system
- B. Genitourinary system
- C. Cardiovascular system
- D. Gastrointestinal system
Correct Answer: C
Rationale: Children with Down syndrome are prone to congenital cardiovascular system deformities.
What is the priority preoperative nursing care of this newborn?
- A. Keep the sac dry.
- B. Diaper snugly.
- C. Position prone in an incubator.
- D. Move from side to side every hour.
Correct Answer: C
Rationale: The infant with meningomyelocele is placed prone in a humidified incubator with the sac covered with sterile saline dressings to protect the lesion.
How should the nurse position this infant?
- A. Prone, with the head of the bed elevated
- B. Supine, with the head flat
- C. Side-lying on the operative side
- D. In a semi-Fowler's position
Correct Answer: D
Rationale: A semi-Fowler's position promotes drainage from the ventricles through the shunt in an infant with bulging fontanelles post-ventriculoperitoneal shunt.