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 B
Explanation
A) "Have you tried holding your infant skin-to-skin?":
While skin-to-skin contact can be beneficial for infant bonding and comfort, the priority for a postoperative infant following a cleft palate repair is to ensure adequate feeding. While skin-to-skin contact can promote bonding and provide comfort, it does not directly address the infant's ability to latch on during breastfeeding, which is crucial for nutritional intake and healing postoperatively.
B) "Is your infant able to latch on during breastfeeding?":
This question addresses the priority concern for the nurse, which is the infant's ability to effectively latch on during breastfeeding. Adequate latch is essential for proper nutrition and hydration, especially for an infant recovering from a cleft palate repair surgery. The nurse needs to assess whether the infant can latch on properly to ensure adequate feeding and support optimal healing.
C) "What is your infant's level of activity?":
While assessing the infant's level of activity is important for overall health and well-being, it is not the priority question in this scenario. The nurse's primary focus should be on assessing the infant's feeding ability and ensuring adequate nutritional intake postoperatively.
D) "Have you considered joining a parents' support group?":
Joining a parents' support group can be valuable for emotional support and sharing experiences, but it is not the priority question in this situation. The immediate concern is ensuring the infant's nutritional needs are being met, particularly in the context of breastfeeding challenges following cleft palate repair surgery.
Correct Answer is D
Explanation
A) Determine possible alternatives:
After identifying the ethical problem, determining possible alternatives comes later in the ethical reasoning process. This step involves brainstorming potential courses of action or solutions to address the ethical dilemma.
B) Examine the outcomes:
Examining the outcomes occurs after identifying possible alternatives. In this step, the nurse evaluates the potential consequences or outcomes of each alternative to determine which course of action aligns best with ethical principles and achieves the desired goals.
C) Develop a plan of action:
Developing a plan of action is a subsequent step in the ethical reasoning process, following the identification of the problem and consideration of possible alternatives. Once the nurse has evaluated the outcomes of various options, they can formulate a plan that outlines the chosen course of action and its implementation steps.
D) Identify the problem:
Identifying the problem is the first step in the ethical reasoning process. This involves recognizing the presence of an ethical dilemma or issue that requires resolution. By clearly defining the problem, the nurse can begin to explore relevant ethical principles, values, and considerations to guide decision-making and problem-solving.
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