Situation: A nurse in a level II nursery of a provincial hospital cares for newborns with risk factors identified at birth. A student nurse cares for a breastfed newborn receiving phototherapy for hyperbilirubinemia. Which action by the student requires the nurse to **INTERVENE**?

Oils and lotions are not applied to the skin during phototherapy because they can cause burns; the other actions are correct phototherapy care.

Why oil is contraindicated during phototherapy

Phototherapy lowers serum bilirubin by delivering light in the blue-green spectrum to the skin. The light penetrates the skin and converts unconjugated bilirubin into water-soluble photoisomers that the newborn can excrete without hepatic conjugation ^[1][3]. For this process to work safely, the skin must be exposed directly to the light source. Applying baby oil or lotion creates a film over the skin that alters light transmission and can intensify local heat absorption, increasing the risk of thermal injury or burns. This is the reason the student nurse's action of applying baby oil before turning on the lights is the one requiring immediate intervention ^[1].

Watch out! The burn risk is not only about the oil itself becoming warm; the oil can act as a lens or barrier that changes how light energy is distributed across the skin. In optimized nursing care protocols for phototherapy, skin emollients, oils, and lotions are specifically listed as items to avoid during active treatment ^[1].

Why the other actions are appropriate

Turning the lights off during blood sampling is correct practice. When serum bilirubin is measured, the phototherapy lights should be temporarily switched off so that the blood sample reflects the actual circulating bilirubin level rather than a value artificially lowered by ongoing photoisomerization at the skin surface ^[1][3]. This prevents a falsely reassuring result.

Removing eye shields during breastfeeding is also appropriate. Eye shields protect the retina from light exposure, but they must be removed periodically so the nurse can assess the eyes for discharge, irritation, or pressure injury. Breastfeeding is a natural time to do this because the newborn is awake and the nurse is already at the bedside ^[1]. The shields are reapplied as soon as feeding and eye assessment are complete.

Leaving the newborn in a small diaper only maximizes the skin surface area exposed to phototherapy light. The greater the exposed area, the more effective the bilirubin reduction ^[1][3]. A diaper is kept in place for hygiene and to protect the genital area, but the rest of the body remains bare.

Clinical reasoning for the licensure exam

This question tests whether you can distinguish safe phototherapy care from an action that causes harm. The key principle is that anything applied to the skin during phototherapy can interfere with light delivery and increase burn risk. Oils, lotions, ointments, and petroleum-based products are all avoided ^[1]. The other three options reflect standard, evidence-aligned phototherapy nursing care: interrupt light for accurate bilirubin sampling, remove eye shields for eye assessment during feeding, and expose as much skin as safely possible ^[1][3].

Key point! When a question asks which action requires intervention, look for the option that adds a substance to the skin during active phototherapy. That is the unsafe action, because it compromises both treatment efficacy and skin safety ^[1].

Action	Safe during phototherapy?	Rationale
Turn lights off for serum bilirubin draw	Yes	Prevents falsely low bilirubin from ongoing photoisomerization [1][3]
Remove eye shields during breastfeeding	Yes	Allows eye assessment and comfort; shields are reapplied after [1]
Apply baby oil before lights on	No	Increases burn risk and alters light transmission [1]
Leave only a small diaper on	Yes	Maximizes skin exposure for effective bilirubin reduction [1][3]

Pathophysiology link to hyperbilirubinemia

Newborns develop hyperbilirubinemia because of increased red blood cell turnover, immature hepatic uptake and conjugation, and enhanced enterohepatic circulation. Phototherapy works on bilirubin already deposited in the skin and subcutaneous tissue. The light energy converts the bilirubin molecule into lumirubin and other photoisomers that are more water-soluble and can be excreted in bile and urine without needing hepatic glucuronidation ^[3]. This is why maximizing skin exposure matters, and why any barrier on the skin—such as oil—reduces the efficiency of this conversion while adding a thermal hazard ^[1].

Watch out! In clinical practice, some caregivers may think oil keeps the skin from drying under the lights. That is a misconception. The correct approach is to monitor skin integrity frequently and keep the newborn well hydrated through feeding, not to apply emollients during phototherapy ^[1].

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