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 C
Explanation
A) Restraining a client without a provider's prescription:
This action represents assault and false imprisonment rather than negligence. Assault involves the threat of harm or unwanted touching, while false imprisonment involves the unlawful restraint or restriction of a person's freedom of movement.
B) Threatening to administer a medication a client has refused:
Threatening to administer a medication against a client's wishes may constitute assault or battery, depending on the circumstances, but it does not directly relate to negligence unless the threat results in harm due to the nurse's failure to adhere to the standard of care.
C) Failing to notify the provider after a medication error:
Negligence involves a breach of duty of care resulting in harm to another person. Failing to notify the provider after a medication error represents negligence because it breaches the duty of care owed to the client and may result in harm if appropriate actions are not taken promptly to mitigate the error's effects.
D) Documenting false information in a client's medical record:
Documenting false information in a client's medical record is a form of falsifying documentation and can have serious consequences, including legal and professional repercussions. However, it does not directly relate to negligence unless the false documentation leads to harm or adverse outcomes for the client.
Correct Answer is A
Explanation
A) Use diluted bleach to clean soiled equipment: This is the correct answer. Clostridium difficile is a bacterium that can form spores, which are resistant to many common disinfectants. Diluted bleach (sodium hypochlorite) is effective in killing C. difficile spores, making it an essential part of infection control protocols for clients with C. difficile infection. It is recommended to use a dilution of 1:10 bleach to water for environmental cleaning.
B) Provide a room with negative-pressure airflow: While negative-pressure rooms may be used for clients with certain airborne infections to prevent the spread of pathogens, it is not typically necessary for clients with C. difficile infection. Standard precautions, including meticulous hand hygiene and appropriate environmental cleaning, are the primary measures for preventing transmission.
C) Wear an N95 respirator when caring for the client: N95 respirators are recommended for healthcare workers caring for clients with airborne infections such as tuberculosis or certain respiratory viruses. C. difficile is transmitted primarily through contact with contaminated surfaces or feces, so standard precautions, including gloves and gowns, are sufficient for preventing transmission.
D) Disinfect hands using an alcohol-based waterless antiseptic: While alcohol-based hand sanitizers are effective against many types of bacteria and viruses, they may not be sufficient for eliminating C. difficile spores. Handwashing with soap and water is preferred for removing C. difficile spores from hands.
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