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 A

Explanation

Rationale:

A. Administering oxygen helps improve oxygenation to the fetus and is the priority intervention for late decelerations.

B. Amnioinfusion may be considered for variable decelerations caused by oligohydramnios but is not indicated for late decelerations.

C. Instructing the client to bear down and push with contractions is not appropriate for addressing late decelerations and may worsen fetal distress.

D. Placing the client in a supine position can exacerbate late decelerations by reducing blood flow to the uterus and should be avoided.

A. Administer oxygen via nonrebreather mask at 8 L/min. B. Cover the umbilical cord with a sterile saline-saturated towel. C. Initiate an infusion of IV fluids for the client. D. Perform a vaginal examination by applying upward pressure on the presenting part.

Correct Answer is D

Explanation

Rationale:

A. Administering oxygen via a nonrebreather mask may be indicated for fetal distress, but the priority in this situation is to protect the umbilical cord from compression and minimize fetal compromise.

B. Cover the umbilical cord with a sterile saline-saturated towel is an appropriate action to prevent the cord from drying out and to reduce infection butimmediate focus should be on relieving pressure on the umbilical cord to ensure adequate fetal perfusion.

C. Initiate an infusion of IV fluids for the client can help stabilize maternal hemodynamics, but it does not directly address the umbilical cord compression. Relieving the pressure on the cord is the immediate intervention to prevent fetal hypoxia.

D. Perform a vaginal examination by applying upward pressure on the presenting part is the priority intervention. In cases of umbilical cord prolapse, the nurse must perform a vaginal examination and apply upward manual pressure on the presenting part (usually the fetal head) to lift it off the umbilical cord. This action relieves compression on the cord and restores blood flow and oxygen delivery to the fetus until an emergency delivery can be performed.

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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?

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