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

To allow manifestations of infection to be identified

The newborn weighs less than 2.5 kg (5.5 lb)

The newborn was delivered via cesarean birth

Answer and Explanation

The Correct Answer is A

A. To facilitate bonding between the newborn and parent. This is correct. Antibiotic ophthalmic ointment, typically used to prevent neonatal conjunctivitis, can temporarily blur the newborn's vision. Delaying its application for a short period allows the newborn to maintain eye contact with the parent during the critical bonding period immediately following birth.

B. To allow manifestations of infection to be identified. This is incorrect. The purpose of the antibiotic ointment is to prevent neonatal conjunctivitis caused by gonorrhea or chlamydia, which may not present with immediate symptoms. Delaying its application to observe for signs of infection would not be appropriate.

C. The newborn's weight is not a determining factor for delaying the instillation of antibiotic ophthalmic ointment.

D. The mode of delivery, whether vaginal or cesarean, does not affect the timing of antibiotic ophthalmic ointment instillation.

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Correct Answer is B

Explanation

Rationale:

A. Vaginal candidiasis would not typically contraindicate the use of a suppository for constipation.

B. A third-degree perineal laceration involves injury to the anal sphincter and rectal mucosa, making the use of a suppository contraindicated due to the risk of exacerbating the injury and causing further discomfort.

C. Abdominal distention may indicate constipation, which could be a reason for using a suppository, rather than a contraindication.

D. Afterpains, or uterine cramping after childbirth, would not typically contraindicate the use of a suppository for constipation.

A. Allow the baby to feed at least every 3 hr. B. Feed the newborn 5 to 10 min per breast. C. Offer the newborn 30 mL (1 oz) of water between feedings. D. Expect two to four wet diapers every 24 hr.

Correct Answer is A

Explanation

Rationale:

A. Allowing the baby to feed at least every 3 hours helps ensure an adequate milk supply and supports newborn growth and development.

B. Timing for breastfeeding sessions can vary and should be guided by the baby's cues rather than a set time limit.

C. Breast milk provides all the hydration a newborn needs; offering water between feedings is unnecessary and may interfere with breastfeeding.

D. Newborns typically produce more than two to four wet diapers every 24 hours; this number may vary but is generally higher.

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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

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