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 B
A) A newborn has an Apgar score of 7 at 5 min after birth:
An Apgar score of 7 at 5 minutes after birth is within the expected range and does not require an incident report. Apgar scores are used to assess a newborn's overall condition at birth, and a score of 7 indicates the infant is in good condition.
B) A newborn has respiratory distress and requires oxygen:
This event warrants completing an incident report because respiratory distress in a newborn requiring oxygen may indicate a significant clinical issue that needs to be investigated further. An incident report allows for documentation and investigation of the event to ensure appropriate actions are taken to address the newborn's condition and prevent similar incidents in the future.
C) A newborn receives erythromycin ophthalmic ointment 4 hr after birth:
Administering erythromycin ophthalmic ointment to newborns is a routine procedure to prevent ophthalmia neonatorum and does not require an incident report unless there is an adverse reaction or error in administration.
D) A newborn receives a heel stick on the outer aspect of the heel:
Heel sticks are commonly performed for newborn screening tests, such as blood glucose or bilirubin levels. Unless there is an error in the procedure or an adverse event related to the heel stick, it does not necessitate an incident report.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A) Notify the nurse manager:
While it's essential to involve the nurse manager in situations involving unexpected events or emergencies, the immediate priority is to assess the well-being of the fainting family member. Notifying the nurse manager can be done after ensuring the family member's immediate needs are addressed.
B) Check the family member's vital signs:
The first action the nurse should take is to assess the fainting family member's vital signs to determine their current physiological status. Checking vital signs can provide crucial information about the person's condition and guide further actions. This assessment helps ensure the family member's safety and well-being.
C) Obtain the family member's health history:
Obtaining the family member's health history is important for understanding any underlying medical conditions that may have contributed to the fainting episode. However, assessing vital signs takes precedence to address any immediate medical concerns related to the fainting episode.
D) Complete an incident report:
Completing an incident report is necessary to document the fainting episode for organizational records and quality improvement purposes. However, this task can be completed after addressing the immediate needs of the fainting family member and ensuring their safety.
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.
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