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?

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.

A) Examine personal values:

While examining personal values is important in ethical decision-making, it is not the first step in addressing this particular ethical dilemma. Understanding personal values comes after gathering relevant facts and understanding the situation fully.

B) Collect the relevant facts:

This is the most appropriate initial step when facing an ethical dilemma. Gathering relevant information about the child's condition, the prescribed treatment, and the reasons for the parents' refusal is crucial for making informed decisions and developing a plan of action.

C) Create a plan of action:

Creating a plan of action is an important step in addressing the ethical dilemma, but it should come after collecting all relevant facts. Without a clear understanding of the situation, any plan of action may be incomplete or ineffective.

D) Agree on a desired outcome:

While determining a desired outcome is essential, it should be based on a thorough understanding of the situation, which comes from collecting relevant facts. Agreeing on an outcome before fully assessing the situation may lead to premature or uninformed decisions.