A new born with 15.3 mg/dl Bilirubin level is admitted in the nursery (NICU) for the management of hyperbilirubinaemia. The baby need for phototherapy. Which of the following nursing intervention is correct?

1. A

   Change position every 2 hourly

2. B

   Check activity every 4 hourly

3. C

   Remove eye shields twice in a day

4. D

   Provide breast feeding every 4 hourly

Appeared in: NORCET -4 , 2023

Explanation

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• Phototherapy is effective when a large surface area of the skin is exposed to the light.
• Changing the infant's position every 2 hours ensures that different areas of the skin are exposed, maximizing the breakdown of bilirubin.
• This intervention also prevents complications such as skin irritation and pressure sores from lying in one position for too long.

Why Other Options Were Wrong

• Option B: Monitoring activity and vital signs every 4 hours is too infrequent for a neonate undergoing phototherapy. These infants are at risk for temperature instability and dehydration.
• Option C: Removing eye shields only twice a day is insufficient. It increases the risk of eye irritation, infection, and deprives the infant of visual stimulation and bonding during feeds.
• Option D: Feeding every 4 hours is not frequent enough. Adequate hydration is crucial to flush out the broken-down bilirubin. Infrequent feeding can lead to dehydration and worsen jaundice.

Related Visual

Clinical Relevance

• Nursing practice connection: Prioritize focused assessment, early escalation, and real-time monitoring when managing Nursing management of neonatal hyperbilirubinemia with phototherapy in acute care settings.
• The nurse's primary role in phototherapy is to maximize its effectiveness while ensuring the infant's safety and preventing complications.
• Failure to implement correct nursing interventions, such as frequent position changes and feeding, can delay the reduction of bilirubin levels and prolong the hospital stay.
• What if? If the infant's temperature becomes unstable (e.g., drops below 36.5°C or rises above 37.5°C), the nurse must intervene immediately. This could involve adjusting the room temperature, adding or removing blankets (if appropriate), or temporarily pausing phototherapy and notifying the physician, as temperature instability can be a sign of sepsis or a complication of the therapy itself.

How to Approach the Question

• First, identify the core of the question: it asks for the 'correct' nursing intervention for a newborn under phototherapy.
• Analyze the patient's condition: a newborn with significant hyperbilirubinemia (15.3 mg/dl) requiring phototherapy.
• Evaluate each option based on the principles of phototherapy management.
• Option A (position change q2h): Does this maximize light exposure and prevent harm? Yes.
• Option B (activity check q4h): Is this frequent enough for a vulnerable neonate under therapy? No, monitoring should be more frequent.
• Option C (eye shields removal 2x/day): Is this frequent enough for assessment and bonding? No, it should be with every feed (q2-3h).

Concept Tested & Keywords

• Concept Tested: Nursing management of neonatal hyperbilirubinemia with phototherapy.
• Stem keywords: new born, Bilirubin level, hyperbilirubinaemia, phototherapy, nursing intervention
• Lead-in keywords: correct
• Clinical cues: Bilirubin level of 15.3 mg/dl indicates the need for treatment in a newborn.

Question ID

QVmbJQ3CJkwvEOJCv76sfy

Copy ID

Reference Book

E6 Text Book Of Pediatric Nursing 3rd Panchali Pal — Part 1 (pp 36-238 of 713) p. 193-195

E6 Ghai Essential Pediatrics(pp 26-904 of 913) p. 173-175

E6 Nelson Textbook of Pediatrics(2024) — Volume 1 p. 1124-1126