A nurse is caring for a newborn immediately following birth.

For which of the following reasons should the nurse delay the instillation of antibiotic ophthalmic ointment?

To facilitate bonding between the newborn and parent.

The newborn weighs less than 2.5 kg (5.5 lb).

To allow manifestations of infection to be identified.

The newborn was delivered via cesarean birth.

Answer and Explanation

The Correct Answer is A

Choice A rationale
The instillation of antibiotic ophthalmic ointment is delayed to facilitate bonding between the newborn and the parent. Immediate skin-to-skin contact between the newborn and the parent has been shown to have several benefits, including stabilizing the newborn’s heart rate, temperature, and breathing, stimulating digestion, helping the newborn to sleep, promoting weight gain, and aiding in maternal attachment.
Choice B rationale
The newborn’s weight does not affect the timing of the instillation of antibiotic ophthalmic ointment.
Choice C rationale
Manifestations of infection in the newborn’s eyes would not be immediately apparent following birth, so this would not be a reason to delay the instillation of antibiotic ophthalmic ointment.
Choice D rationale
The mode of delivery, whether vaginal or cesarean, does not affect the timing of the instillation of antibiotic ophthalmic ointment.

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Correct Answer is B

Explanation

The correct answer is choiceb. Do you notice increased cramping with breastfeeding?

Choice A rationale:Swelling in the feet is not directly related to the need for PRN pain medication following a cesarean birth. Swelling can be a common postpartum symptom due to fluid retention and changes in blood chemistry, but it does not specifically indicate pain that requires medication.

Choice B rationale:Increased cramping with breastfeeding is a common occurrence due to the release of oxytocin, which causes uterine contractions. This can be quite painful and may necessitate PRN pain medication to manage the discomfort.

Choice C rationale:Leakage from the incision could indicate a complication such as infection or wound dehiscence. While this is a serious concern that requires medical attention, it is not directly related to the typical pain management needs following a cesarean birth.

Choice D rationale:The ability to pass gas is an important indicator of the return of bowel function after surgery, but it is not directly related to the need for PRN pain medication. It is more relevant to assessing gastrointestinal recovery rather than pain levels.

A. Apply oxygen at 2 L/min via nasal cannula. B. Massage the client’s fundus. C. Turn the client to a side-lying position. D. Assist the client to empty their bladder.

Correct Answer is C

Explanation

Choice A rationale
Applying oxygen at 2 L/min via nasal cannula may be beneficial for a client experiencing hypotension following the administration of epidural anesthesia, but it is not the primary action a nurse should take.
Choice B rationale
Massaging the client’s fundus is not an appropriate action for a nurse to take when a client is hypotensive following the administration of epidural anesthesia.
Choice C rationale
Turning the client to a side-lying position is a recommended intervention for hypotension following epidural anesthesia. This position helps improve venous return to the heart and can help alleviate hypotension by reducing aortocaval compression.
Choice D rationale
Assisting the client to empty their bladder may be beneficial in certain circumstances, but it is not the primary action a nurse should take when a client is hypotensive following the administration of epidural anesthesia.

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A nurse is caring for a newborn immediately following birth. For which of the following reasons should the nurse delay the instillation of antibiotic ophthalmic ointment?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is assessing a client for pain following a cesarean birth 24 hours ago. Which should the nurse ask to determine if a PRN pain medication is needed?

Correct Answer is B

Explanation

A nurse is caring for a client who is hypotensive following the administration of epidural anesthesia. Which action should the nurse take?

Correct Answer is C

Explanation

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A nurse is assessing a newborn whose mother had gestational diabetes mellitus. The nurse should monitor for which of the following findings as a manifestation of hypoglycemia?

A nurse is caring for a newborn immediately following birth.

For which of the following reasons should the nurse delay the instillation of antibiotic ophthalmic ointment?