A nurse is planning care immediately following birth for a newborn who has a myelomeningocele that is leaking cerebrospinal fluid. Which of the following actions should the nurse include in the plan of care?

Rationale:

A. Determining the client's apical pulse rate is important for monitoring the effects of digoxin therapy but does not directly assess medication adherence.

B. Asking the client if they are taking the medication as prescribed is a direct way to evaluate medication adherence. Open communication with the client can provide valuable insight into their medication-taking behavior.

C. Assessing the client's kidney function is important for monitoring the effects of digoxin therapy but does not directly assess medication adherence.

D. Checking the client's serum medication level can provide information about medication concentration but may not necessarily indicate adherence, as the level could be within the therapeutic range even if the client is not taking the medication as prescribed.

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.