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 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.

A. "I respect your right to choose to discontinue treatment." B. "I will have a hospice nurse come discuss this kind of care with you. C. "I will answer any questions you have about hospice care honestly." D. "I work with hospice services to help you transition to their care."

Correct Answer is C

Explanation

A) "I respect your right to choose to discontinue treatment."

While this statement acknowledges the client's autonomy and right to make decisions about their care, it does not directly address the nurse's commitment to honesty or transparency in discussing hospice care.

B) "I will have a hospice nurse come discuss this kind of care with you."

While involving a hospice nurse is a supportive action, it does not directly demonstrate the nurse's commitment to honesty or openness in discussing hospice care with the client.

C) "I will answer any questions you have about hospice care honestly."

This statement demonstrates veracity by explicitly stating the nurse's commitment to providing truthful and accurate information about hospice care. It reassures the client that they can trust the nurse to provide honest answers to their questions.

D) "I work with hospice services to help you transition to their care."

While this statement indicates the nurse's involvement in facilitating the transition to hospice care, it does not specifically address the nurse's commitment to honesty or truthfulness in discussing hospice care with the client.

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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

Naxlex Comprehensive Predictor Exams

A nurse in a long-term care facility is collecting data for an interprofessional care conference for a client who has Parkinson's disease. Which of the following findings is the priority for the nurse to report at the conference?

Correct Answer is D

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?

Correct Answer is C

Explanation

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