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 C

Explanation

Choice A rationale
Polyuria, or excessive urination, is not typically associated with the administration of an epidural block with an opioid analgesic.
Choice B rationale
Bilateral crackles in the lungs can be a sign of a respiratory condition such as pneumonia or heart failure. However, they are not a common side effect of an epidural block with an opioid analgesic.
Choice C rationale
Hypotension, or low blood pressure, is a known side effect of epidural analgesia. This is due to the blockade of the sympathetic chain, which can contribute to hypotension. Therefore, it is important for the nurse to monitor the client’s blood pressure during the administration of an epidural block with an opioid analgesic.
Choice D rationale
Hyperglycemia, or high blood sugar, is not typically a side effect of an epidural block with an opioid analgesic. Hyperglycemia is more commonly associated with conditions such as diabetes.

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 who has a prescription for erythromycin ophthalmic ointment. The guardian refuses the medication. Which action should the nurse take?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is providing care to a client who is receiving an epidural block with an opioid analgesic. Which of the following findings should the nurse monitor as a potential adverse effect of the medication?

Correct Answer is C

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 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?