A nurse is planning care for a newborn who is receiving phototherapy for an elevated bilirubin
level. Which of the following actions should the nurse take? - CORRECT ANSWER D. Use a
photometer to monitor the lamp's energy
The nurse should monitor the lamp's energy throughout the therapy to ensure the newborn is
receiving the appropriate amount to be effective.
A nurse is assessing a client at 34 weeks gestation who has a mild placental abruption. Which
of the following findings should the nurse expect? - CORRECT ANSWER Dark red vaginal
bleeding
The nurse should expect this client with a mild placental abruption to have minimal dark red
vaginal bleeding.
A nurse is assessing a newborn and notes an axillary temperature of 96.9°F (36°C). Which of
the following actions should the nurse perform? - CORRECT ANSWER Correct Answer:
B.
Assess the newborn's blood glucose level
Infants who become cold attempt to generate heat through increased muscular and metabolic
activity. This process increases glucose consumption and puts the newborn at risk of
hypoglycemia.
Incorrect Answers:
A. The nurse should not obtain a rectal temperature from a newborn due to the risk of rectal
perforation. Instead, the nurse should obtain an axillary temperature.
C. Bathing a newborn will increase heat loss. The infant should not be bathed until the
temperature has stabilized within the normal range.
D. Placing the infant in front of a heater vent can incur heat loss through convection.
Additionally, there is a potential fire risk from the bassinet linens and the vent.
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