A father observing his newborn’s admission to the nursery notices that eye ointment is applied to the infant’s eyes.
He asks the nurse about the purpose of the ointment.
What would be the correct response from the nurse regarding the purpose of the ointment?
To prevent herpes infection
To prevent eye infections
To clear the infant’s vision
To dilate the pupil so the red reflex can be visualized
To dilate the pupil so the red reflex can be viWhat would be the correct response from the nurse regarding the purpose of the ointment?
The Correct Answer is B
Choice A rationale
While it is true that the ointment can help prevent certain types of infections, it is not specifically intended to prevent herpes infection. Herpes is a viral infection, and the ointment is an antibiotic, which is used to prevent bacterial infections.
Choice B rationale
The primary purpose of eye ointment is to protect newborns from serious eye infections caused by common bacteria. Mothers who have a sexually transmitted infection (STI) can pass it to their newborns during childbirth, putting them at risk for an eye infection known as ophthalmia neonatorum (ON)3.
Choice C rationale
The ointment does not serve to clear the infant’s vision. It is applied to the eyes to prevent bacterial infections, not to improve or alter the infant’s vision.
Choice D rationale
The ointment is not used to dilate the pupil to visualize the red reflex. The red reflex is a reflection from the lining of the eye that is often observed when looking at the pupil, but this is not related to the application of the ointment.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A rationale
A heart rate of 58 beats/minute is within the normal range for adults, including those who have recently given birth. Therefore, there is no need to report this to the healthcare provider.
Choice B rationale
While assessing for excessive lochia is important in postpartum care, there is no indication from the given vital signs that this is necessary.
Choice C rationale
The vital signs provided are all within normal ranges for a postpartum patient. Therefore, the appropriate action would be to document these findings in the patient’s record.
Choice D rationale
There is no indication from the given vital signs that the patient has a fever or pain, so administering a PRN dose of acetaminophen is not necessary.
Correct Answer is B
Explanation
Choice A rationale
If the child is sleeping now and is difficult to wake, this could be a sign of worsening respiratory status. Children with respiratory distress often have difficulty sleeping due to discomfort and difficulty breathing. If the child is now sleeping and difficult to wake, this could indicate a decrease in oxygen levels, leading to lethargy and decreased responsiveness. This would require immediate attention.
Choice B rationale
The vital signs provided indicate a potentially serious situation. A heart rate of 130 beats/minute is high for a 3-year-old child, indicating that the heart is working harder to pump blood. A respiratory rate of 15 breaths/minute is on the lower end of normal for a 3-year-old, which could indicate that the child is not getting enough oxygen. An oxygen saturation of 66% on a 5L face mask is dangerously low, indicating severe hypoxia. A temperature of 102.8° F(39.3° C) axillary indicates a fever, which could be a sign of infection. A blood pressure of 92/48 mm Hg is within normal range for a 3-year-old.
Choice C rationale
If the child is active and playing with toys, this could indicate that his respiratory status is not worsening. Children who are experiencing respiratory distress often have difficulty engaging in normal activities due to discomfort and shortness of breath. If the child is able to play normally, this could indicate that he is getting enough oxygen and his condition is stable.
Choice D rationale
If the child’s breathing has returned to normal, this could indicate that his respiratory status is improving. However, it’s important to continue monitoring the child closely, as respiratory conditions can change rapidly, especially in young children.
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