A nurse in the newborn nursery is providing care for four newborns. For which of the following events should the nurse plan to complete an incident report?
A newborn has an Apgar score of 7 at 5 min after birth.
A newborn has respiratory distress and requires oxygen.
A newborn receives erythromycin ophthalmic ointment 4 hr after birth.
A newborn receives a heel stick on the outer aspect of the heel.
The Correct Answer is C
Answer: C. A newborn receives erythromycin ophthalmic ointment 4 hr after birth.
Rationale:
A. A newborn has an Apgar score of 7 at 5 min after birth:
An Apgar score of 7 is within the acceptable range and does not indicate an adverse event or require an incident report. This score reflects a newborn transitioning well to extrauterine life with only mild adjustments needed.
B. A newborn has respiratory distress and requires oxygen:
While respiratory distress requires prompt intervention, it can be an expected complication in some neonates. Administering oxygen in this context is an appropriate clinical response, not a reportable incident.
C. A newborn receives erythromycin ophthalmic ointment 4 hr after birth:
Erythromycin should be administered within 1 to 2 hours after birth to prevent ophthalmia neonatorum. A 4-hour delay exceeds this timeframe and poses a potential risk to the infant’s health, qualifying as a deviation from standard protocol that warrants an incident report.
D. A newborn receives a heel stick on the outer aspect of the heel:
Performing a heel stick on the outer aspect of the heel is the correct location to avoid nerve and bone injury. This is a safe and standard practice and does not require an incident report.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A) "I will contact the provider to let her know":
This response acknowledges the client's uncertainty about the procedure and indicates the nurse's commitment to address the client's concerns promptly by involving the healthcare provider. Contacting the provider allows for further discussion of the client's decision and consideration of any alternatives or additional information needed to support the client's choice.
B) "You should discuss your concerns with your family":
While involving family members in decision-making can be beneficial, especially for emotional support, the client's decision about the procedure is ultimately theirs to make. Encouraging discussion with family members without addressing the client's immediate concerns may not effectively address the situation.
C) "This procedure is perfectly safe":
Asserting the safety of the procedure without addressing the client's uncertainties or reasons for hesitation may not adequately address the client's concerns. It's essential to acknowledge and explore the client's apprehensions rather than dismissing them outright.
D) "Why are you changing your mind about the procedure?":
This response may come across as confrontational and may put the client on the defensive. It's important to approach the situation with empathy and support, allowing the client to express their concerns openly without feeling judged or pressured.
Correct Answer is B
Explanation
A) Contact the nurse from the previous shift to report the doubled dose:
While it may be appropriate to communicate with the nurse from the previous shift to gather information about the medication administration, contacting them solely to report the doubled dose may not be the most effective action. The priority is to ensure appropriate documentation of the incident and take necessary steps to address it.
B) Document the doubled dose in the client's medical record:
Documenting the doubled dose in the client's medical record is essential for accurate and transparent documentation of the incident. This documentation should include details such as the medication, dosage, time of administration, and any actions taken in response to the error. It ensures that all members of the healthcare team are aware of what occurred and facilitates appropriate follow-up and monitoring.
C) Place a copy of the incident report in the client's record:
While completing an incident report is necessary to formally document the medication error and initiate an investigation, simply placing a copy of the report in the client's record may not be sufficient. The incident report typically serves as an internal document used for quality improvement purposes and may not be part of the client's official medical record.
D) Report the incident to the manager of the pharmacy:
Reporting the incident to the manager of the pharmacy may be appropriate for addressing potential medication dispensing errors or system issues but may not be the immediate action required when a medication error occurs at the administration stage. The first priority is to ensure accurate documentation of the error in the client's medical record.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.