A nurse is reinforcing teaching to a student on newborn erythromycin 0.9% ophthalmic ointment administration.
Which of the following statements by the nurse should be included in the teaching? (Select All that Apply.)

"This medication is administered to prevent neonatal ophthalmia.”.

"Only newborns born to clients with STIs should receive this medication.”.

"I will clean the newborn's eyes from inner to outer canthus before administration.”.

"I will wait at least one minute after administration before wiping the excess.”.

Answer and Explanation

Correct Answer : A,C,D

Choice A rationale

This statement is correct. Erythromycin 0.5% ophthalmic ointment is routinely administered to newborns to prevent ophthalmia neonatorum, which is an infection of the newborn's eyes caused by bacteria such as *Neisseria gonorrhoeae* or *Chlamydia trachomatis* acquired during passage through the birth canal.

Choice B rationale

This statement is incorrect. While the medication prevents neonatal ophthalmia caused by sexually transmitted infections (STIs), it is routinely administered to *all* newborns regardless of the mother's STI status. This is due to the potential for asymptomatic maternal infection and to ensure broad-spectrum prophylaxis.

Choice C rationale

This statement is correct. Cleaning the newborn's eyes from inner to outer canthus before administration removes any discharge or meconium that could interfere with medication absorption or introduce further contamination, ensuring optimal efficacy and preventing the spread of potential pathogens during application.

Choice D rationale

This statement is correct. Waiting at least one minute after administration before wiping the excess allows the medication sufficient time to spread across the conjunctival sac and be absorbed by the ocular tissues, maximizing its prophylactic effect against potential bacterial pathogens present on the eye surface.

Choice E rationale

This statement is incorrect. While the medication does treat conjunctivitis, its primary purpose in newborns is prophylactic, meaning it is given to *prevent* neonatal ophthalmia, not to treat existing conjunctivitis. It is administered to all newborns as a preventative measure against specific bacterial infections.

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Correct Answer is B

Explanation

Choice A rationale

A fetal heart rate of 160 to 190 beats per minute is elevated and falls outside the normal physiological range. This sustained tachycardia can indicate fetal distress, such as hypoxia or infection, and warrants immediate investigation and potential intervention to ensure adequate oxygenation and fetal well-being.

Choice B rationale

A fetal heart rate of 110 to 160 beats per minute is considered the normal range for a healthy fetus. This range reflects proper autonomic nervous system regulation, adequate oxygenation, and overall fetal well-being, indicating a balanced interplay between sympathetic and parasympathetic influences on cardiac activity.

Choice C rationale

A fetal heart rate of 100 to 110 beats per minute is below the normal range, indicating mild bradycardia. While sometimes benign, persistent bradycardia can signal fetal compromise, such as umbilical cord compression or placental insufficiency, requiring close monitoring and further assessment.

Choice D rationale

A fetal heart rate of 80 to 100 beats per minute is significantly below the normal range, indicating severe bradycardia. This marked decrease in heart rate is a critical sign of significant fetal distress, often associated with severe hypoxia or acidosis, and necessitates immediate medical intervention.

A. "You should not eat or drink for 8 hours before the test.”. B. "Since you have no chronic illnesses, your test results should be fine.”. C. "You will be on bed rest for 4 hours after the test.”. D. "It is a screening test so it does not actually diagnose anomalies.”.

Correct Answer is D

Explanation

Choice A rationale

An alpha-fetoprotein (AFP) test is a blood test that measures the levels of AFP in the maternal serum. This test does not require any specific dietary restrictions, such as fasting. Therefore, advising the client to abstain from food or drink for 8 hours before the test is not based on physiological necessity for accurate AFP measurement.

Choice B rationale

Test results are influenced by various factors, including gestational age, multiple pregnancies, and certain fetal anomalies. While chronic illnesses can impact overall health, they do not directly determine the outcome of an AFP screening test, which primarily assesses the risk of neural tube defects or chromosomal abnormalities.

Choice C rationale

An AFP test is a simple blood draw and is not an invasive procedure. Therefore, there is no physiological need for bed rest following the test. Clients can resume their normal activities immediately after the blood sample is collected, as there are no associated post-procedure complications requiring immobility.

Choice D rationale

The AFP test is a screening tool, meaning it identifies individuals who may be at an increased risk for certain conditions, such as neural tube defects or Down syndrome. It does not provide a definitive diagnosis. Abnormal screening results necessitate further diagnostic testing, such as amniocentesis or high-resolution ultrasound, for confirmation.

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A nurse is reinforcing teaching to a student on newborn erythromycin 0.9% ophthalmic ointment administration. Which of the following statements by the nurse should be included in the teaching? (Select All that Apply.)

Nursing Test Bank

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Correct Answer is B

Explanation

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Correct Answer is D

Explanation

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A nurse is reinforcing teaching to a student on newborn erythromycin 0.9% ophthalmic ointment administration.
Which of the following statements by the nurse should be included in the teaching? (Select All that Apply.)