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.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A) Vital signs flow sheet:
While vital signs are essential for assessing the client's health status, the home health agency typically focuses on the client's ongoing care needs rather than retrospective data such as vital sign trends.
B) Nursing admission assessment:
The nursing admission assessment provides valuable information about the client's initial condition upon admission to the acute care facility. However, the home health agency primarily requires information relevant to the client's current health status and ongoing care needs.
C) Current medications:
Providing the home health agency with a list of the client's current medications is essential for continuity of care. It allows the home health agency to ensure that the client receives the appropriate medications and dosages after discharge. This information helps prevent medication errors, adverse drug interactions, and omissions in the client's care plan. Additionally, the home health agency can use the medication list to reconcile medications and update the client's medication regimen as needed.
D) Nurses' notes:
While nurses' notes contain valuable information about the client's care during their stay in the acute care facility, they may not be immediately relevant to the home health agency's provision of care in the community setting. The focus of the home health agency is typically on the client's current status and needs rather than historical documentation.
Correct Answer is B
Explanation
A) Informed consent:
While informed consent documents provide information about the proposed surgical procedure, they typically do not include information about organ donation. Informed consent focuses on the risks, benefits, and alternatives of the procedure being performed, as well as the client's agreement to undergo the procedure.
B) Advance directives:
Advance directives, such as a living will or healthcare proxy, can contain information about a client's preferences regarding organ donation. These documents specify the client's wishes regarding medical interventions, including organ donation, in the event that they become incapacitated and unable to make decisions for themselves. Advance directives guide healthcare providers and family members in honoring the client's preferences regarding end-of-life care and organ donation.
C) Do-not-resuscitate order:
A do-not-resuscitate (DNR) order instructs healthcare providers not to perform cardiopulmonary resuscitation (CPR) in the event of cardiac or respiratory arrest. While organ donation preferences may be discussed in the context of end-of-life care decisions, a DNR order specifically pertains to resuscitative measures and does not provide information about organ donation.
D) Provider's prescription:
A provider's prescription typically pertains to specific medications or treatments ordered by the healthcare provider for the client's care. It does not typically contain information about organ donation. Organ donation preferences are typically documented in advance directives or other specific forms related to donation programs.
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