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
While monitoring glucose levels is important in newborn care, it is not specifically related to breastfeeding frequency and voiding patterns.
Choice B rationale
While assessing the newborn’s head and sclera color is part of a comprehensive newborn examination, it is not specifically related to breastfeeding frequency and voiding patterns.
Choice C rationale
While monitoring the newborn’s respiratory rate is crucial in newborn care, it is not specifically related to breastfeeding frequency and voiding patterns.
Choice D rationale
Monitoring intake and output is directly related to breastfeeding frequency and voiding patterns. A newborn who has been breastfeeding 3 to 4 times per day should have passed meconium stool by 36 hours old. The absence of meconium stool could indicate a problem and should be reported to the provider.

A. You should store your diaphragm in sterile water after each use. B. You should use an oil-based vaginal lubricant when inserting your diaphragm. C. You should keep the diaphragm in place for at least 4 hours after intercourse. D. You should have your provider refit you for a new diaphragm.

Correct Answer is D

Explanation

Choice A rationale
Storing a diaphragm in sterile water after each use is not necessary. After use, the diaphragm should be washed with mild soap and warm water, then air-dried.
Choice B rationale
Using an oil-based vaginal lubricant when inserting a diaphragm is not recommended. Oil- based lubricants can damage the material of the diaphragm, reducing its effectiveness.
Choice C rationale
Keeping the diaphragm in place for at least 4 hours after intercourse is correct, but it does not address the client’s postpartum status.
Choice D rationale
The client should have her provider refit her for a new diaphragm. After childbirth, a woman’s body undergoes changes that may affect the fit of her diaphragm. It is recommended that a woman be refitted for a diaphragm around 6 weeks postpartum, when the uterus and cervix have returned to normal size.

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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

Correct Answer is D

Explanation

A nurse is providing teaching to a client who is 2 days postpartum and wants to continue using her diaphragm for contraception. Which of the following instructions should the nurse include?

Correct Answer is D

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?