The nurse is preparing to care for a newborn receiving phototherapy. Which interventions are appropriate? (Select all that apply.)
a. Avoid stimulation.
b. Decrease fluid intake.
c. Expose all the newborn's skin.
d. Monitor skin temperature closely.
e. Reposition the newborn every 2 hours.
f. Cover the newborn's eyes with eye shields or patches.
ANS: D, E, F
Several nursing interventions are instituted to protect the newborn during phototherapy. Temperature is closely monitored to prevent hyperthermia or hypothermia. The newborn is repositioned every 2 hours to maximize exposure to the phototherapy and to prevent skin breakdown. The infant's eyes are shielded by an opaque mask to prevent exposure to the light. The newborn is clothed in a diaper because a side effect of phototherapy includes loose, greenish stools. Other side effects include increased metabolic rate; dehydration; electrolyte disturbances, such as hypocalcemia; and priapism. Infants receiving phototherapy may require additional fluid volume to compensate for insensible and intestinal fluid loss. The infant should receive adequate stimulation, which includes feeding and touching.
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