A father watching the admission of his newborn to the nursery notices that eye ointment is placed in the infant's eyes. He asks the nurse what the purpose of the ointment is. Which response by the nurse will best explain the purpose for administering the ointment?
"The ointment will dilate the pupil so the red reflex can be visualized.”.
"The ointment will prevent a herpes infection.”.
"The ointment will clear the infant's vision.”.
"The ointment will prevent eye infections.”. . . .
The Correct Answer is D
Choice A rationale
Ophthalmic ointments like erythromycin or tetracycline do not have properties that dilate the pupils. Their chemical composition is designed to inhibit bacterial growth. Pupillary dilation is typically achieved with mydriatic agents, which are not included in these prophylactic treatments. The red reflex is a normal finding and not the purpose of the medication.
Choice B rationale
While the ointment is effective against certain sexually transmitted infections, a herpes simplex virus infection is a viral infection. The prophylactic ophthalmic ointments are bacteriostatic or bactericidal, specifically targeting bacterial pathogens like Neisseria gonorrhoeae and Chlamydia trachomatis. They are not effective in preventing viral infections.
Choice C rationale
The ointment is a thick, viscous substance that can temporarily cause blurred vision immediately after administration. It does not clear the infant's vision; rather, it is a prophylactic measure to prevent a severe infection that could lead to corneal scarring and blindness. The visual effect is temporary and not therapeutic.
Choice D rationale
Prophylactic ophthalmic ointment, typically erythromycin or tetracycline, is administered to all newborns to prevent ophthalmia neonatorum, which is an eye infection caused by bacteria such as Neisseria gonorrhoeae and Chlamydia trachomatis. These bacteria can be transmitted from the mother's birth canal and can cause serious eye damage, including blindness.
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Correct Answer is D
Explanation
Choice A rationale
Rubbing the infant's back provides tactile stimulation, which can encourage deeper breaths and a more vigorous cry, aiding in the transition to extrauterine life. While this is a valid intervention for a sluggish infant, it may not be necessary if the respiratory rate is already within the normal range of 30-60 breaths/minute. Cyanosis of the hands and feet (acrocyanosis) is a common, benign finding.
Choice B rationale
Assessing bowel sounds is part of a comprehensive newborn assessment but is not a priority in a situation where the nurse is evaluating respiratory status and color. Bowel sounds provide information about gastrointestinal function and are not directly related to the infant's oxygenation or transition to extrauterine life. This assessment would be performed after ensuring adequate cardiorespiratory function.
Choice C rationale
Intubation is an invasive procedure reserved for infants who are not breathing or have severe respiratory distress, such as a respiratory rate below 30 breaths/minute or persistent central cyanosis. A respiratory rate of 40 breaths/minute is within the normal range for a newborn, indicating adequate respiratory effort. Therefore, intubation is not warranted at this time.
Choice D rationale
Acrocyanosis, or cyanosis of the hands and feet, is a normal physiological finding in the first 24 hours of life due to immature peripheral circulation. The infant's respiratory rate of 40 breaths/minute is within the expected range for a newborn (30-60 breaths/minute). The combination of a normal respiratory rate and benign acrocyanosis indicates the infant is transitioning normally, and continued monitoring is the appropriate action.
Correct Answer is B
Explanation
Choice A rationale
Chlamydia trachomatis is a sexually transmitted infection that can cause neonatal conjunctivitis and pneumonia if the newborn is exposed during vaginal delivery. However, if the infection was treated at least 7 days prior to delivery, the risk of transmission is significantly reduced, and a cesarean section is not indicated for this reason.
Choice B rationale
Active herpes simplex virus (HSV) lesions on the perineum present a significant risk of transmitting the virus to the neonate during vaginal delivery. Neonatal herpes is a serious, often fatal, condition. Therefore, a primary cesarean section is performed to prevent the newborn from coming into contact with the lesions.
Choice C rationale
A positive Western blot for HIV indicates the presence of the virus. A cesarean section is sometimes recommended to reduce the risk of perinatal HIV transmission, but a vaginal birth is not an absolute contraindication, especially if the client has a low viral load from effective antiretroviral therapy.
Choice D rationale
Group B Streptococcus (GBS) is a common bacterium that can colonize the vagina and rectum. It can cause serious infections in newborns. However, the standard of care is to administer intrapartum antibiotic prophylaxis to the mother, not to perform a cesarean section, to prevent transmission.
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