A nurse is planning care for a full-term newborn who is receiving phototherapy. Which of the following actions should the nurse include in the plan of care?

Correct Answer: B

Rationale: The correct answer is B: Avoid using lotion or ointment on the newborn skin. Phototherapy is used to treat jaundice by exposing the baby's skin to light. Lotions or ointments can interfere with the effectiveness of the light therapy. Dressing the newborn in lightweight clothing (choice A) is not directly related to the effectiveness of phototherapy. Keeping the newborn supine throughout treatment (choice C) is a general position recommendation and not specific to phototherapy. Measuring the newborn's temperature every 8 hours (choice D) is important but not directly related to phototherapy.

Correct Answer: B

Rationale: The correct answer is B: Monitor contractions every 30 min. During the transition phase of labor, contractions are typically intense and frequent. Monitoring contractions every 30 minutes allows the nurse to assess the progress of labor and ensure the safety of both the mother and the baby. This helps in identifying any abnormalities or complications that may arise during this critical stage. A: Assisting the client to void every 3 hr is important, but it is not specific to the transition phase of labor. C: Placing the client into a lithotomy position is not recommended during the transition phase as it can restrict blood flow and increase the risk of complications. D: Encouraging the client to use a pant-blow breathing pattern is a relaxation technique more suited for the earlier stages of labor, not the transition phase.

Correct Answer: A

Rationale: The correct answer is A: Ampicillin. Group B Streptococcus (GBS) infection during labor is typically treated with intravenous antibiotics like ampicillin to prevent transmission to the newborn. Ampicillin is the first-line treatment for GBS during labor due to its effectiveness in eradicating the bacteria and reducing the risk of neonatal infection. Azithromycin (B) is not typically used for GBS infection during labor. Ceftriaxone (C) is not the preferred antibiotic for GBS during labor. Acyclovir (D) is used to treat viral infections, not bacterial infections like GBS.

Correct Answer: B

Rationale: The correct answer is B: Risk for injury. This is because families with special needs in childbearing may face unique challenges leading to potential risks of injury, such as physical limitations or difficulties in providing adequate care. Option A is incorrect as spiritual distress is not directly related to physical safety. Option C is incorrect as enhanced nutrition readiness does not directly address safety concerns. Option D is incorrect as ineffective breathing pattern is a specific health issue not necessarily related to the family's safety. Therefore, B is the most appropriate nursing diagnosis for addressing safety concerns in the childbearing family with special needs.

Correct Answer: D

Rationale: The correct answer is D: Heartburn may be relieved by sitting up after. This is because during pregnancy, the growing uterus can push stomach acids upward, causing heartburn. Sitting up after eating can help prevent acid reflux by allowing gravity to keep stomach contents down. Choice A is incorrect as increased saliva production during pregnancy is not related to toothbrush hardness. Choice B is incorrect because uteroplacental insufficiency is not related to the client's gastrointestinal system. Choice C is incorrect as umbilical cord compression is a separate issue and not related to heartburn relief.