A nurse in the newborn nursery is providing care for four newborns. For which of the following events should the nurse plan to complete an incident report?

A newborn has an Apgar score of 7 at 5 min after birth.

A newborn has respiratory distress and requires oxygen.

A newborn receives erythromycin ophthalmic ointment 4 hr after birth.

A newborn receives a heel stick on the outer aspect of the heel.

Answer and Explanation

The Correct Answer is C

Answer: C. A newborn receives erythromycin ophthalmic ointment 4 hr after birth.

Rationale:

A. A newborn has an Apgar score of 7 at 5 min after birth:
An Apgar score of 7 is within the acceptable range and does not indicate an adverse event or require an incident report. This score reflects a newborn transitioning well to extrauterine life with only mild adjustments needed.

B. A newborn has respiratory distress and requires oxygen:
While respiratory distress requires prompt intervention, it can be an expected complication in some neonates. Administering oxygen in this context is an appropriate clinical response, not a reportable incident.

C. A newborn receives erythromycin ophthalmic ointment 4 hr after birth:
Erythromycin should be administered within 1 to 2 hours after birth to prevent ophthalmia neonatorum. A 4-hour delay exceeds this timeframe and poses a potential risk to the infant’s health, qualifying as a deviation from standard protocol that warrants an incident report.

D. A newborn receives a heel stick on the outer aspect of the heel:
Performing a heel stick on the outer aspect of the heel is the correct location to avoid nerve and bone injury. This is a safe and standard practice and does not require an incident report.

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Correct Answer is A

Explanation

A) Initiate oxygen therapy via nasal cannula for a client who has COPD:

Clients with chronic obstructive pulmonary disease (COPD) often have impaired gas exchange and may experience acute exacerbations requiring oxygen therapy to improve oxygenation and alleviate respiratory distress. Oxygen therapy is a critical intervention to address hypoxemia and prevent complications such as respiratory failure. Therefore, initiating oxygen therapy for a client with COPD is the highest priority among the options provided.

B) Initiate a 24-hr urine collection for a client who has end-stage kidney disease:

Initiating a 24-hour urine collection is an important nursing task for clients with end-stage kidney disease to monitor renal function and assess urine output. However, compared to the immediate need for oxygen therapy in a client with COPD, starting a urine collection is a lower priority and can be scheduled once the client's respiratory needs are addressed.

C) Administer an antibiotic for a client who has methicillin-resistant Staphylococcus aureus:

Administering antibiotics for a client with methicillin-resistant Staphylococcus aureus (MRSA) infection is important to control the spread of infection and prevent complications. However, unless the client's condition is critically unstable or the antibiotic administration is time-sensitive, addressing oxygenation needs for a client with COPD takes precedence due to the potential for respiratory compromise and hypoxemia.

D) Change the dressing for a client who has a decubitus ulcer:

Changing dressings for clients with decubitus ulcers is essential for wound care management and prevention of infection. While maintaining skin integrity is important, addressing respiratory distress in a client with COPD is a higher priority to ensure adequate oxygenation and prevent respiratory compromise.

A. The client reports insomnia. B. The client requires additional help to stand. C. The client has increased difficulty dressing. D. The client has difficulty swallowing.

Correct Answer is D

Explanation

A) The client reports insomnia:

Insomnia is a common symptom in Parkinson's disease but may not pose an immediate threat to the client's health or require urgent intervention compared to other symptoms such as difficulty swallowing.

B) The client requires additional help to stand:

While needing assistance to stand is indicative of the progression of Parkinson's disease and may require attention, it is not typically considered a priority over symptoms that directly impact the client's safety and well-being.

C) The client has increased difficulty dressing:

Increased difficulty dressing is a manifestation of Parkinson's disease progression and may impact the client's independence and quality of life. However, it is not as immediately life-threatening as difficulty swallowing.

D) The client has difficulty swallowing:

Difficulty swallowing, or dysphagia, is a serious concern in Parkinson's disease as it can lead to aspiration, malnutrition, dehydration, and respiratory complications such as pneumonia. It poses a significant risk to the client's safety and requires prompt attention to prevent complications. Therefore, it is the priority finding to report at the interprofessional care conference.

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A nurse in the newborn nursery is providing care for four newborns. For which of the following events should the nurse plan to complete an incident report?

Nursing Test Bank

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Correct Answer is A

Explanation

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Correct Answer is D

Explanation

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