A nurse is caring for a newborn immediately following birth who has a prescription for erythromycin ophthalmic ointment.

The guardian refuses the medication. Which action should the nurse take?

Document the guardian’s refusal of the medication.

Inform the guardian that the medication can be given after discharge.

Report the guardian’s refusal of the medication to social services.

Notify the facility’s ethics committee about the guardian’s medication refusal.

Answer and Explanation

The Correct Answer is A

Choice A rationale
Erythromycin ophthalmic ointment is administered to newborns to prevent neonatal conjunctivitis, also known as ophthalmia neonatorum, specifically for Neisseria gonorrhoeae infection prevention. If the guardian refuses the administration of erythromycin, the healthcare provider should respect the guardian’s decision and document the refusal. It’s important to note that the refusal should be informed, meaning the guardian should understand the potential risks associated with not administering the medication.
Choice B rationale
Informing the guardian that the medication can be given after discharge may not be the best course of action. The purpose of the ointment is to prevent infection immediately after birth when the risk is highest. Delaying the administration could potentially increase the risk of the newborn developing an infection.
Choice C rationale
Reporting the guardian’s refusal of the medication to social services is not the first step unless there are other concerns about the safety or well-being of the child. The healthcare provider should respect the guardian’s autonomy and their right to make informed decisions about the newborn’s care.
Choice D rationale
Notifying the facility’s ethics committee about the guardian’s medication refusal is not typically necessary unless the refusal puts the newborn at significant risk and other attempts to resolve the situation have failed. In this case, the refusal of erythromycin ophthalmic ointment, while not ideal, is not likely to warrant an ethics consultation.

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Correct Answer is D

Explanation

Choice A rationale
Preterm newborns do not have a thick layer of brown fat. Brown fat is a type of fat that generates heat and is typically found in full-term newborns. It helps them maintain their body temperature. Preterm newborns have less brown fat, which makes them more susceptible to hypothermia.
Choice B rationale
Shivering is a mechanism used by the body to generate heat when it’s cold. However, preterm newborns cannot shiver. Their nervous systems are not fully developed, and they lack the muscle coordination necessary to shiver.
Choice C rationale
Sweating is another mechanism the body uses to regulate temperature. When the body is too warm, it produces sweat to cool down. However, preterm newborns do not sweat to cool off when they get too warm. Their sweat glands are not fully developed, and they may not be able to sweat effectively.
Choice D rationale
Preterm newborns have less muscle tone, which exposes more body surfaces to heat loss. Muscle tone provides insulation and generates heat. Because preterm newborns have less muscle mass, they have less insulation and generate less heat, making them more susceptible to hypothermia.

A. Provide the newborn with 15 mL glucose water after each feeding. B. Close the newborn’s eyes before applying eyepatches. C. Apply hydrating lotion to the newborn’s skin prior to treatment. D. Turn the newborn every hour.

Correct Answer is B

Explanation

Choice A rationale
Providing the newborn with 15 mL glucose water after each feeding is not a recommended action for a newborn undergoing phototherapy for jaundice. While maintaining adequate hydration is important, feedings should consist of breast milk or formula, unless otherwise directed by a healthcare provider.
Choice B rationale
Before starting phototherapy, it’s important to protect the newborn’s eyes from the light by applying eye patches. This can help prevent potential damage to the retinas.
Choice C rationale
Applying hydrating lotion to the newborn’s skin prior to treatment is not a recommended action for a newborn undergoing phototherapy for jaundice. The light needs to be able to penetrate the skin in order to break down the bilirubin, and applying lotion could potentially interfere with this process.
Choice D rationale
Turning the newborn every hour is not a recommended action for a newborn undergoing phototherapy for jaundice. While it’s important to change the newborn’s position regularly to ensure that all areas of the skin are exposed to the light, this does not need to be done on an hourly basis.

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A nurse is caring for a newborn immediately following birth who has a prescription for erythromycin ophthalmic ointment. The guardian refuses the medication. Which action should the nurse take?

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A nurse is caring for a newborn immediately following birth who has a prescription for erythromycin ophthalmic ointment.

The guardian refuses the medication. Which action should the nurse take?