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

To allow manifestations of infection to be identified

The newborn weighs less than 2.5 kg (5.5 lb)

The newborn was delivered via cesarean birth

Answer and Explanation

The Correct Answer is A

A. To facilitate bonding between the newborn and parent. This is correct. Antibiotic ophthalmic ointment, typically used to prevent neonatal conjunctivitis, can temporarily blur the newborn's vision. Delaying its application for a short period allows the newborn to maintain eye contact with the parent during the critical bonding period immediately following birth.

B. To allow manifestations of infection to be identified. This is incorrect. The purpose of the antibiotic ointment is to prevent neonatal conjunctivitis caused by gonorrhea or chlamydia, which may not present with immediate symptoms. Delaying its application to observe for signs of infection would not be appropriate.

C. The newborn's weight is not a determining factor for delaying the instillation of antibiotic ophthalmic ointment.

D. The mode of delivery, whether vaginal or cesarean, does not affect the timing of antibiotic ophthalmic ointment instillation.

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Correct Answer is A

Explanation

Rationale:

A. The McRoberts maneuver involves flexing the mother's thighs onto her abdomen to straighten the pelvis and allow for easier passage of the baby's shoulder. This action helps to widen the pelvic outlet and facilitate delivery.

B. Applying pressure to the client's fundus is not part of the McRoberts maneuver. Fundal pressure may be used in other techniques to manage shoulder dystocia, such as the Rubin maneuver or Woods' screw maneuver.

C. Pressing firmly on the client's suprapubic area is not part of the McRoberts maneuver. This action may be performed in conjunction with other maneuvers to help dislodge the impacted shoulder.

D. Moving the client onto their hands and knees is not part of the McRoberts maneuver. This position, known as the Gaskin maneuver, may be used as an alternative maneuver to alleviate shoulder dystocia by changing the orientation of the pelvis.

A. Excessive crying B. Decreased muscle tone C. Absent Moro reflex D. Diminished deep tendon reflexes

Correct Answer is A

Explanation

Rationale:

A. Excessive crying:

Correct answer. Neonatal abstinence syndrome (NAS) often presents with irritability, inconsolable crying, and difficulty soothing.

B. Decreased muscle tone: NAS can cause hypertonia or increased muscle tone rather than decreased muscle tone.

C. Absent Moro reflex: NAS may cause hyperactive Moro reflex rather than absent.

D. Diminished deep tendon reflexes: NAS can cause hyperactive deep tendon reflexes rather than diminished.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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