Page 856 - Saunders Comprehensive Review For NCLEX-RN

establish appropriate sleep-rest cycles in the newborn as well. Options 1, 2, and 3 are
inappropriate interventions.
Test-Taking Strategy: Note the strategic word, priority. Think about the
pathophysiology that occurs in a newborn with this condition. Also, use Maslow’s
Hierarchy of Needs theory to direct you to the correct option. Remember that
nutrition is a priority.
Level of Cognitive Ability: Creating
Client Needs: Physiological Integrity
Integrated Process: Nursing Process—Planning
Content Area: Maternity: Newborn
Health Problem: Newborn: Addicted Newborn
Priority Concepts: Addiction; Clinical Judgment
Reference: McKinney et al. (2018), pp. 1348-1349.

278. Answer: 4

Rationale: Erythromycin ophthalmic ointment 0.5% is used as a prophylactic
treatment for ophthalmia neonatorum, which is caused by the bacterium Neisseria
gonorrhoeae. Preventive treatment of gonorrhea is required by law. Options 1, 2, and
3 are not the purposes for administering this medication to a newborn infant.
Test-Taking Strategy: Note the strategic word, best. Use knowledge of the purpose
of administering erythromycin ophthalmic ointment to a newborn infant. Remember
that this is done to prevent ophthalmia neonatorum.
Level of Cognitive Ability: Applying
Client Needs: Health Promotion and Maintenance
Integrated Process: Teaching and Learning
Content Area: Maternity: Newborn
Health Problem: Newborn: Infections
Priority Concepts: Health Promotion; Infection
Reference: McKinney et al. (2018), pp. 462-463.

279. Answer: 4, 5, 6

Rationale: Phototherapy (bili-light or bili-blanket) is the use of intense fluorescent
light to reduce serum bilirubin levels in the newborn. Adverse effects from
treatment, such as eye damage, dehydration, or sensory deprivation, can occur.
Interventions include exposing as much of the newborn’s skin as possible; however,
the genital area is covered. The newborn’s eyes are also covered with eye shields or
patches, ensuring that the eyelids are closed when shields or patches are applied.
The shields or patches are removed at least once per shift to inspect the eyes for
infection or irritation and to allow eye contact. The nurse measures the lamp energy
output to ensure efficacy of the treatment (done with a special device known as a
photometer), monitors skin temperature closely, and increases fluids to compensate
for water loss. The newborn may have loose green stools and green-colored urine.
The newborn’s skin color is monitored with the fluorescent light turned off every 4
to 8 hours and is monitored for bronze baby syndrome, a grayish brown
discoloration of the skin. The newborn is repositioned every 2 hours, and stimulation

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