A nurse is assessing a newborn following a forceps-assisted birth.
Which of the following clinical manifestations should the nurse identify as a complication of this birth method?

Choice A rationale
The weight of the newborn is not a factor in the decision to delay the instillation of antibiotic ophthalmic ointment. The ointment is used to prevent eye infections caused by bacteria present in the mother’s birth canal, and this risk is not related to the newborn’s weight.
Choice B rationale
Whether the newborn was delivered via cesarean birth or vaginal birth does not affect the decision to delay the instillation of antibiotic ophthalmic ointment. The ointment is used to prevent eye infections that can occur regardless of the method of delivery.
Choice C rationale

While it is important to monitor newborns for signs of infection, delaying the instillation of antibiotic ophthalmic ointment would not aid in identifying manifestations of infection. The ointment is a preventative measure and does not interfere with the observation of symptoms.
Choice D rationale
Correct answer. The instillation of antibiotic ophthalmic ointment can cause blurred vision in the newborn. Delaying the instillation of the ointment facilitates immediate bonding between the newborn and parent, as the newborn will be able to see more clearly.

Choice A rationale
Applying a moist, warm compress to the perineum is not the recommended care for a client with a fourth-degree laceration of the perineum 12 hr postpartum.
Choice B rationale

Administering methylergonovine 0.2 mg IM is not the recommended care for a client with a fourth-degree laceration of the perineum 12 hr postpartum. Methylergonovine is a medication used to prevent or control bleeding of the uterus following childbirth or abortion.
Choice C rationale
Providing the client with a cool sitz bath is the correct action. A sitz bath can help to soothe the perineal area, reduce inflammation, and promote healing.
Choice D rationale
Applying povidone-iodine to the client’s perineum after she voids is not the recommended care for a client with a fourth-degree laceration of the perineum 12 hr postpartum. Povidone-iodine is an antiseptic used for skin disinfection before and after surgery.