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 B

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

An Apgar score of 7 at 5 minutes after birth is within the expected range and does not require an incident report. Apgar scores are used to assess a newborn's overall condition at birth, and a score of 7 indicates the infant is in good condition.

B) A newborn has respiratory distress and requires oxygen:

This event warrants completing an incident report because respiratory distress in a newborn requiring oxygen may indicate a significant clinical issue that needs to be investigated further. An incident report allows for documentation and investigation of the event to ensure appropriate actions are taken to address the newborn's condition and prevent similar incidents in the future.

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

Administering erythromycin ophthalmic ointment to newborns is a routine procedure to prevent ophthalmia neonatorum and does not require an incident report unless there is an adverse reaction or error in administration.

D) A newborn receives a heel stick on the outer aspect of the heel:

Heel sticks are commonly performed for newborn screening tests, such as blood glucose or bilirubin levels. Unless there is an error in the procedure or an adverse event related to the heel stick, it does not necessitate an incident report.

Nursing Test Bank

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

Correct Answer is C

Explanation

A) Tying the restraint to the bed frame: This action is appropriate and ensures that the restraint is anchored securely to the bed frame, preventing the client from removing it independently. Tying the restraint to the bed frame is a standard practice to maintain the client's safety.

B) Applying the restraint over the client's gown: While it's generally preferable to apply restraints directly to the client's skin to minimize movement and ensure effectiveness, applying the restraint over the gown is acceptable in some situations. However, it's essential to ensure that the restraint is snug and properly secured to prevent the client from slipping out of it.

C) Placing the restraint across the client's chest: Placing the restraint across the client's chest is not recommended because it can restrict chest expansion and interfere with breathing, potentially leading to respiratory compromise. Restraints should be applied to minimize movement while allowing the client to breathe comfortably.

D) Using a quick-release knot to secure the restraint: Using a quick-release knot is essential when applying restraints to ensure that they can be quickly removed in case of an emergency or if the client experiences distress. This promotes client safety and allows for rapid intervention if needed.

A. Includes quotes from the client B. Remains logged in to the charting system throughout the shift C. Makes reference in the nurses notes of completing an incident report D. Documents that the provider wrote an inaccurate prescription

Correct Answer is A

Explanation

A) Includes quotes from the client:

Including direct quotes from the client in documentation provides accurate information about the client's statements or expressions. This practice enhances the clarity and validity of the documentation, as it captures the client's own words, which may be important for conveying their thoughts, feelings, or symptoms.

B) Remains logged in to the charting system throughout the shift:

Remaining logged in to the charting system throughout the shift poses a security risk and violates principles of confidentiality. Nurses should log out of the system when not actively using it to prevent unauthorized access to sensitive patient information.

C) Makes reference in the nurse's notes of completing an incident report:

While documenting the completion of an incident report is important for communication and quality improvement purposes, referencing it directly in the nurse's notes may not be appropriate. Incident reports are typically separate documents used for reporting adverse events or incidents, and their contents may not be part of the client's medical record.

D) Documents that the provider wrote an inaccurate prescription:

Documenting that the provider wrote an inaccurate prescription is not within the scope of a nurse's documentation responsibilities. If a nurse identifies an inaccurate prescription, the appropriate action is to clarify the prescription with the provider through established communication channels rather than documenting the error in the client's chart.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

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

Naxlex Comprehensive Predictor Exams

A nurse is observing an assistive personnel (AP) apply a belt restraint on a client. Which of the following actions by the AP requires intervention by the nurse?

Correct Answer is C

Explanation

A charge nurse is reviewing the computer documentation of a newly licensed nurse. Which of the following practices by the newly licensed nurse should the charge nurse identify as appropriate documentation practice?

Correct Answer is A

Explanation

A nurse is caring for a client who has a terminal illness and wishes to discuss hospice care. Which of the following statements by the nurse demonstrates veracity?

A nurse is admitting a client for an elective surgical procedure. During the client interview. one of the client's family members faints. Which of the following actions should the nurse take first?

A nurse is reinforcing teaching about torts with a newly licensed nurse. The nurse should include which of the following as an example of negligence?

A nurse is caring for a client who has type 1 diabetes mellitus. Which of following actions should the nurse take first when providing morning care?

A nurse is reinforcing teaching with a group of newly licensed nurses about client rights. Which of the following scenarios should the nurse include as an example of a client rights violation for which a nurse should intervene? (Select all that apply).

A nurse is reinforcing teaching with the family of an older adult client about safety precautions. Which of the following recommendations should the nurse include to reduce the risk of a client fall? (Select a that apply)

A nurse is assisting with the discharge of a client from acute care to home health care. Which of the following components of the medical record should the nurse provide to the home health agency?

A nurse is assisting with the plan of care for a child whose parents refuse to accept the medical treatment prescribed by the provider. Which of the following actions should the nurse plan to take first to address this ethical dilemma?