A nurse is planning care for a client who is in labor and has gonorrhea. Which of the following actions should the nurse include in the plan for delivery?
Instill erythromycin ointment into the newborn's eyes.
Give oral sulfadiazine to the mother prior to delivery.
Administer penicillin G procaine IM to the newborn.
Apply miconazole vaginal cream to the mother prior to delivery.
The Correct Answer is A
A. Instill erythromycin ointment into the newborn's eyes: Erythromycin ophthalmic ointment is routinely applied to all newborns to prevent ophthalmia neonatorum, a serious eye infection caused by exposure to Neisseria gonorrhoeae during birth.
B. Give oral sulfadiazine to the mother prior to delivery: Sulfonamides are not recommended for gonorrhea treatment in laboring clients and are ineffective in preventing neonatal eye infections.
C. Administer penicillin G procaine IM to the newborn: Penicillin is used to treat confirmed neonatal infections, not as a routine prophylaxis against gonococcal eye infections.
D. Apply miconazole vaginal cream to the mother prior to delivery: Miconazole is an antifungal used for vaginal yeast infections and has no effect on gonorrhea, so it is not indicated for preventing neonatal infection.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Rationale:
A. Maintain the irrigation solution rate: Pink-tinged urine is expected in the early hours after a TURP due to residual bleeding from the surgical site. The nurse should continue the current irrigation rate to prevent clot formation and maintain catheter patency.
B. Warm the irrigation solution: Warming the solution is not required for bladder irrigation and does not address the normal postoperative finding of pink-tinged urine. It also does not play a role in preventing clot formation.
C. Perform the Credé's maneuver: This technique, involving manual bladder compression, is not appropriate for a client with a continuous bladder irrigation and indwelling catheter in place. It could cause injury or disrupt the surgical site.
D. Replace the indwelling urinary catheter: There is no indication of catheter blockage or malfunction in this scenario. Replacing the catheter unnecessarily increases infection risk and could damage the urethra or surgical area.
Correct Answer is C
Explanation
A. Explaining the steps for a 24-hr urine collection: Teaching and explaining procedures require nursing knowledge and judgment, which are outside the scope of practice for assistive personnel.
B. Interpreting blood glucose values: Interpretation of lab results requires clinical judgment and assessment skills, which must be performed by a licensed nurse.
C. Performing postmortem care: Postmortem care is a noninvasive task that focuses on preparing the body, maintaining dignity, and basic hygiene. This task is within the scope of practice for assistive personnel.
D. Assisting with low-carbohydrate diet selections: Assisting with dietary teaching or making food choices involves clinical guidance and education, which must be performed by a licensed nurse or dietitian rather than an assistive personnel.
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