Nokea
The nurse must administer erythromycin ophthalmic ointment to a newborn after birth. The nurse should:
- A. instill within 15 minutes of birth for maximum effectiveness
- B. cleanse eyes from inner to outer canthus before administration
- C. apply directly over the cornea.
- D. flush eyes 10 minutes after instillation to reduce irritation
Correct Answer: B
Rationale: Cleansing the eyes from inner to outer canthus ensures that any debris or contaminants are removed before administration, which helps prevent infection and ensures the medication's effectiveness.
You may also like to solve these questions
The nurse is evaluating the involution of a woman who is 3 days post partum. Which of the following finding would the nurse evaluate as normal?
- A. Fundus 1 cm above the umbilicus, lochia rosa.
- B. Fundus 2 cm above the umbilicus, lochia alba.
- C. Fundus 2 cm below the umbilicus, lochia rubra.
- D. Fundus 3 cm below the umbilicus, lochia serosa.
Correct Answer: D
Rationale: By day 3, the fundus should descend to 3 cm below the umbilicus, and lochia should transition to serosa.
A neonates 5-minute Apgar assessment reveals the following: active motion; pulse
- A. 126 beats/minute; grimace and coughing during suctioning; appearance
- B. good color all over; and respirations slightly irregular with weak cry. What action by the nurse is most appropriate?
- C. Assess oxygen saturation and administer oxygen if needed.
- D. Document the findings in the chart and begin the identification process.
Correct Answer: A
Rationale: The babys 5-minute Apgar score is 8 (motion 2; pulse 2; grimace 2; appearance 1; respirations 1). If a 5-minute Apgar score is less than 9 the nurse should stabilize the infant instead of leaving the baby with the parents in the birthing unit. Because it appears that this babys problems are related to either oxygenation or perfusion the nurse should assess the oximetry reading and administer oxygen if needed.
The nurse is assisting a newborn's primary care provider with the performance of a circumcision. Which intervention is used to manage the neonate's pain?
- A. A Velcro tourniquet is loosely wrapped around the penis.
- B. The neonate is breastfed first to promote a sense of calmness.
- C. A sucrose-dipped pacifier is offered during the nerve block.
- D. The foreskin is numbed with ice before the nerve block.
Correct Answer: C
Rationale: The correct answer is C because offering a sucrose-dipped pacifier during the nerve block procedure can help manage the newborn's pain by providing comfort and distraction through the sweet taste and sucking motion. Sucrose has been shown to have analgesic effects in newborns. Choice A is incorrect as a tourniquet is not recommended for circumcision. Choice B may help with calming but not specifically with pain management. Choice D is incorrect as numbing with ice before the nerve block may not be effective in providing adequate pain relief during the procedure.
Why is the Dubowitz/Ballard assessment tool used on newborns following delivery?
- A. To determine whether the infant is transitioning to extrauterine life
- B. To predict any growth and development problems that the infant may have
- C. To determine the neuromuscular and physical maturity of the infant
- D. To compare the newborn with other newborns born at the same gestational age
Correct Answer: C
Rationale: The Dubowitz/Ballard assessment tool is used to determine the neuromuscular and physical maturity of the newborn. This tool assesses various physical and neuromuscular characteristics to estimate the gestational age of the infant accurately. By evaluating factors such as skin texture, lanugo, ear formation, and posture, healthcare providers can assess the infant's developmental stage. This assessment helps in determining if the infant is born prematurely or post-term, guiding appropriate care and interventions. The other choices are incorrect because the tool is not primarily used for those purposes.
A home health nurse visits a 2-week-old infant and observes the umbilical cord has dried and fallen off. The area appears healed with no drainage or erythema present. Given these assessment findings, what instruction should the nurse give the parent?
- A. cover the umbilicus with a band-aid
- B. continue to clean the stump with alcohol for 1 week
- C. apply an antibiotic ointment to the stump
- D. give the baby a bath in an infant tub now
Correct Answer: D
Rationale: The correct answer is D: give the baby a bath in an infant tub now. This instruction is appropriate as the umbilical cord has dried and fallen off, indicating that the area is healed. Giving the baby a bath in an infant tub will help keep the area clean and promote healing.
A: Covering the umbilicus with a band-aid is unnecessary and may hinder air circulation, leading to potential infection.
B: Continuing to clean the stump with alcohol for 1 week is unnecessary as the cord has already fallen off and the area is healed.
C: Applying an antibiotic ointment to the stump is not recommended unless there are signs of infection, which are not present in this case.