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?

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?

Dark red vaginal bleeding

The nurse should expect this client with a mild placental abruption to have minimal dark red vaginal

bleeding.

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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:

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.