A nurse is caring for a newborn immediately following birth.
For which of the following reasons should the nurse delay the instillation of antibiotic ophthalmic ointment?
To facilitate bonding between the newborn and parent.
The newborn weighs less than 2.5 kg (5.5 lb).
To allow manifestations of infection to be identified.
The newborn was delivered via cesarean birth.
The Correct Answer is A
Choice A rationale
The instillation of antibiotic ophthalmic ointment is delayed to facilitate bonding between the newborn and the parent. Immediate skin-to-skin contact between the newborn and the parent has been shown to have several benefits, including stabilizing the newborn’s heart rate, temperature, and breathing, stimulating digestion, helping the newborn to sleep, promoting weight gain, and aiding in maternal attachment.
Choice B rationale
The newborn’s weight does not affect the timing of the instillation of antibiotic ophthalmic ointment.
Choice C rationale
Manifestations of infection in the newborn’s eyes would not be immediately apparent following birth, so this would not be a reason to delay the instillation of antibiotic ophthalmic ointment.
Choice D rationale
The mode of delivery, whether vaginal or cesarean, does not affect the timing of the instillation of antibiotic ophthalmic ointment.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale
Taking a multivitamin daily is generally recommended during pregnancy to ensure the mother and baby receive necessary nutrients. It does not indicate a need for referral to a dietitian.
Choice B rationale
A weight gain of 4.5 kg (10 lb) since a positive pregnancy test could be a concern depending on the timeframe. If this weight gain occurred rapidly, it could indicate issues such as fluid retention or inadequate nutrition, which would warrant a referral to a dietitian.
Choice C rationale
Nausea, particularly in the morning, is a common symptom of early pregnancy often referred to as “morning sickness”. It does not typically require dietary intervention unless it is severe (hyperemesis gravidarum), leading to weight loss and dehydration.
Choice D rationale
Eating prunes is a natural method to manage constipation, a common issue during pregnancy due to hormonal changes that slow digestion. This choice does not indicate a need for a dietitian referral.
Correct Answer is ["B","C","E"]
Explanation
Choice A rationale
Peripheral edema 2+ in bilateral lower extremities is a common finding in the postpartum period and does not necessarily indicate a problem. It can result from the normal fluid shifts that occur after delivery.
Choice B rationale
A blood pressure reading of 136/86 mm Hg is slightly elevated and could indicate the development of postpartum hypertension, a condition that can lead to serious complications such as stroke. This finding necessitates immediate follow-up.
Choice C rationale
Lateral deviation of the uterus could indicate a full bladder, which can interfere with uterine contractions and lead to increased bleeding. This finding necessitates immediate follow-up.
Choice D rationale
Deep tendon reflexes 1+ are within normal limits and do not necessitate immediate follow-up.
Choice E rationale
A large amount of lochia rubra could indicate postpartum hemorrhage, a potentially life- threatening condition. This finding necessitates immediate follow-up.
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