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?
The newborn weighs less than 2.5 kg (5.5 lb).
The newborn was delivered via cesarean birth.
To allow manifestations of infection to be identified.
To facilitate bonding between the newborn and parent.
The Correct Answer is D
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A rationale
Massaging the client’s fundus is not indicated in this situation. Fundal massage is typically done after childbirth to help the uterus contract and prevent excessive bleeding.
Choice B rationale
Applying oxygen can help increase the client’s oxygen saturation levels, but it does not directly address the cause of the hypotension.
Choice C rationale
Turning the client to a side-lying position, specifically the left lateral position, can help improve blood flow to the heart, increasing cardiac output and blood pressure.
Choice D rationale
Assisting the client to empty their bladder is important in postpartum care, but it is not the immediate action to take when a client is hypotensive following the administration of epidural anesthesia.
Correct Answer is A
Explanation
Choice A rationale
Facial petechiae are small, pinpoint, red or purple spots on the skin that can occur when a newborn has a nuchal cord, or the umbilical cord wrapped around the neck. This is due to the pressure exerted on the baby’s face and neck during delivery.
Choice B rationale
Erythema toxicum is a common rash seen in newborns, characterized by tiny bumps surrounded by red skin. However, it is not specifically associated with a nuchal cord.
Choice C rationale
Periauricular papillomas are small skin tags or pits seen near the ear. They are a common minor anomaly seen in newborns, but they are not associated with a nuchal cord.
Choice D rationale
Telangiectatic nevi, also known as “stork bites,” are common birthmarks seen in newborns, characterized by small, light pink patches, usually on the back of the neck. However, they are not associated with a nuchal cord.
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