MATERNAL - High Risk

Question 1

A Newborn is receiving phototherapy. Which intervention by the nurse would be most important?

A. Measurement of HC
B. Encouraging mother to stop Breast Feeding
C. Stool blood testing
D. Assessment of hydration status

Answer 1

D. Assessment of hydration status

Question 2

The nurse is evaluating the effectiveness of phototherapy on Newborn. Which evaluation indicates a therapeutic response to phototherapy?

A. NB maintains a normal temperature
B. Increase serum bilirubin levels
C. Weight loss
D. Skin blanching yellow

Answer 2

A. NB maintains a normal temperature

Question 3

Is the most effective light for reducing the bilirubin is:

A. Blue light
B. White Halogen lights
C. Green light
D. Fluorescent lights

Answer 3

A. Blue light

Question 4

Advantages of phototherapy are: A. Noninvasive B. Effective C. Inexpensive D. Easy to use
A. A, C 
B. A, B
C. B, C, D
D. All choices

Answer 4

D. All choices

Question 5

Which of the following is a sign of hyperbilirubinemia?

A. Yellowish skin
B. Decreased number of stools
C. Decreased number of voids
D. Decreased amount of sleep

Answer 5

A. Yellowish skin

Question 6

Side effects of phototherapy include/s the following, except:

A. Bronze – baby syndrome
B. Transient skin rashes
C. Loose, greenish stool
D. Decreasing metabolic rate

Answer 6

D. Decreasing metabolic rate

Question 7

Phototherapy is stop when the SBR (Serum Bilirubin) for term infants with physiological jaundice is:

A. 260mmol/L
B. 280 mmol/L
C. 290mmol/L
D. 300mmol/L

Answer 7

B. 280 mmol/L

Question 8

Where should overhead phototherapy lights be positioned when treating hyperbilirubinemia?

A. 20 cms
B. 25 cms
C. 45 cms
D. 55 cms

Answer 8

C. 45 cms

Question 9

Which nursing interventions are appropriate when caring for a Newborn undergoing phototherapy? 1. Cover the NB eyes at all times, when not under lights 2. Close the Newborns eyelids before apply eye patches 3. Inspect the eyes each shift for conjunctivitis 4. Keep the baby swaddled in blanket to prevent heat loss 5. Reposition the baby q2hrs

A. 2, 3, 5
B. 2, 3, 4
C. All except 4
D. All the choices

Answer 9

A. 2, 3, 5

Question 10

Blue to green light is the most effective in converting unconjugated bilirubin and considered intensive phototherapy. The wavelengths is:

A. 260 to 290nm
B. 360 to 390nm
C. 460 to 490 nm
D. 560 to 590 nm

Answer 10

C. 460 to 490 nm

Question 11

Phototherapy is ordered for a Newborn with physiologic jaundice. The nurse caring for the infant should:

A. Offer the baby sterile water between feedings of formula
B. Apply an emollient to the baby’s skin to prevent drying
C. Wear a gown, gloves, and a mask while caring for the infant
D. Place the baby on enteric isolation

Answer 11

A. Offer the baby sterile water between feedings of formula

Question 12

A nursing diagnosis for a 5-day-old Newborn under phototherapy is: Risk for fluid volume deficit. For which of the following client outcomes should the nurse plan to monitor the baby?

A. 6 saturated diapers in 24 hours
B. Breastfeeds 6 times in 24 hours
C. 12% weight loss since birth
D. Apical heart rate of 176 bpm

Answer 12

A. 6 saturated diapers in 24 hours

Question 13

Factors affecting efficacy of phototherapy includes the following, except:

A. Light intensity
B. Type of light used
C. Surface area of skin exposed to light
D. The distance of the light source from the baby, the optimum distance being 25 - 50 cm in conventional lights.

Answer 13

D. The distance of the light source from the baby, the optimum distance being 25 - 50 cm in conventional lights.