The nurse is observing a student nurse care for a neonate undergoing intensive phototherapy. Which action by the student nurse indicates that she understands how to provide care for an infant undergoing intensive phototherapy?
1. Urine-specific gravity is assessed each voiding.
2. Eye coverings are left off to help keep the baby calm.
3. Temperature is checked every six hours.
4. The infant is taken out of the isolette for diaper changes.
1
Rationale:
1. This action is correct; urine concentration as indicated by raising urine-specific gravity indicates a need for additional fluids.
2. Eyes should be covered at all times.
3. Six hours is too long; the temperature should be assessed every four hours to prevent hyper- or hypothermia.
4. The infant's care should be clustered to keep the infant under the lights as much as possible. The diaper should have been changed while under the lights in the isolette.
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