A nurse is preparing to assess a client’s conjunctiva.

Identify the sequence the nurse should follow when taking the following actions.

1) Apply examination gloves.

2) Instruct the client to look up.

3) Place the thumbs below each of the client’s lower eyelids.

4) Gently pull the client’s skin down to the top edge of the bony orbital rim.

5) Inspect the color and condition of the conductive and sclera, noting any color change, swelling, drainage, or lesions.

1, 2, 3, 4, 5

2, 1, 4, 3, 5

1, 4, 2, 3, 5

2, 3, 1, 4, 5.

Answer and Explanation

The Correct Answer is A

The nurse should follow the sequence of 1, 2, 3, 4, 5 when assessing the client’s conjunctiva. This is because the nurse should first apply examination gloves to prevent contamination and infection. Then, the nurse should instruct the client to look up to expose the lower eyelid and conjunctiva. Next, the nurse should place the thumbs below each of the client’s lower eyelids and gently pull the skin down to the top edge of the bony orbital rim. This allows the nurse to inspect the color and condition of the conjunctiva and sclera, noting any color change, swelling, drainage, or lesions. The sclera should be white and the conjunctiva should be pink.

Choice B is wrong because the nurse should not pull down the skin before instructing the client to look up.

This could cause discomfort and injury to the eye.

Choice C is wrong because the nurse should not instruct the client to look up after pulling down the skin.

This could also cause discomfort and injury to the eye.

Choice D is wrong because the nurse should not place the thumbs below each of the client’s lower eyelids before applying examination gloves.

This could introduce infection and irritants to the eye.

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Correct Answer is A

Explanation

Apply a thin ribbon of ointment along the inner canthus of each eye.This is the recommended method for administering erythromycin ointment to a newborn’s eyes as prophylaxis for gonorrhea and chlamydia infections.The ointment should be applied into the conjunctival sac to avoid accidental injury to the eye.

ChoiceBis wrong because the eyes should not be wiped off after applying the ointment.The ointment will gradually dissolve and disperse over the eye surface.

ChoiceCis wrong because the medication is an ointment, not a drop.

A drop would not provide adequate coverage of the eye and would be more likely to cause irritation

A. Sunken fontanelles B. Bulging fontanelles C. Diamond-shaped anterior fontanelle D. Triangular posterior fontanelle.

Correct Answer is B

Explanation

Bulging fontanelles.Bulging fontanelles can be a sign of increased intracranial pressure or intracranial and extracranial tumors.This is a potential problem for the newborn’s brain and health and should be evaluated by imaging studies.

Choice A is wrong because sunken fontanelles are usually a sign of dehydration, which is not a problem with the fontanelles themselves, but with the fluid balance of the newborn.

Choice C is wrong because a diamond-shaped anterior fontanelle is normal for a newborn.The anterior fontanelle is the largest and most important for clinical evaluation.It has an average size of 2.1 cm and a median time of closure of 13.8 months.

Choice D is wrong because a triangular posterior fontanelle is also normal for a newborn.The posterior fontanelle is smaller than the anterior one and normally closes by 8 weeks.

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Naxlex Comprehensive Predictor Exams

A nurse is preparing to administer erythromycin ointment to a newborn’s eyes as prophylaxis for gonorrhea and chlamydia infections. Which of the following actions should the nurse take?

Correct Answer is A

Explanation

A nurse is performing a head-to-toe assessment of a newborn. What finding should alert the nurse to a potential problem with the newborn’s fontanelles?

Correct Answer is B

Explanation

A nurse is caring for a newborn who has hyperbilirubinemia and is receiving phototherapy. Which of the following interventions should the nurse implement?

A nurse observes that an infant has an elongated head shape due to molding during delivery. The nurse explains to the parents that this condition is called:

A nurse palpates an infant’s anterior fontanelle and notes that it feels soft and flat when lying down, but slightly elevated when sitting up or crying. What should be included in documentation?

A nurse is caring for a newborn who has an Apgar score of 8 at one minute after birth and an Apgar score of 10 at five minutes after birth. Which statement best describes this newborn’s condition?

Select all that apply. A nurse is providing comfort measures to a newborn during an assessment. What non-pharmacological interventions can the nurse use to soothe the newborn?

A nurse is teaching a class on Apgar scoring to nursing students. Which statement by a student indicates a need for further teaching

A nurse is performing the physical maturity test on a newborn using the New Ballard Scale. What characteristic would the nurse assess?

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