Which nursing diagnosis would be considered a priority for a newborn infant who is receiving phototherapy in an isolette?
a. Hypothermia because of phototherapy treatment
b. Impaired skin integrity related to diarrhea as a result of phototherapy
c. Fluid volume deficit related to phototherapy treatment
d. Knowledge deficit (parents) related to initiation of medical therapy
ANS: C
Infants who undergo phototherapy as a result of the medical diagnosis of hyperbilirubinemia are at risk for hyperthermia, not hypothermia. Although impaired skin integrity can occur, the priority nursing diagnosis focuses on the physiologic effects of fluid volume deficit. The infant is losing fluid via insensible losses, increased output (in the form of diarrhea), and limited intake. Lack of knowledge is a pertinent nursing diagnosis for parents but physiologic needs take precedence.
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