A nurse is caring for a newborn immediately following birth who has a prescription for erythromycin ophthalmic ointment.

The guardian refuses the medication. Which action should the nurse take?

Document the guardian’s refusal of the medication.

Inform the guardian that the medication can be given after discharge.

Report the guardian’s refusal of the medication to social services.

Notify the facility’s ethics committee about the guardian’s medication refusal.

Answer and Explanation

The Correct Answer is A

Choice A rationale
Erythromycin ophthalmic ointment is administered to newborns to prevent neonatal conjunctivitis, also known as ophthalmia neonatorum, specifically for Neisseria gonorrhoeae infection prevention. If the guardian refuses the administration of erythromycin, the healthcare provider should respect the guardian’s decision and document the refusal. It’s important to note that the refusal should be informed, meaning the guardian should understand the potential risks associated with not administering the medication.
Choice B rationale
Informing the guardian that the medication can be given after discharge may not be the best course of action. The purpose of the ointment is to prevent infection immediately after birth when the risk is highest. Delaying the administration could potentially increase the risk of the newborn developing an infection.
Choice C rationale
Reporting the guardian’s refusal of the medication to social services is not the first step unless there are other concerns about the safety or well-being of the child. The healthcare provider should respect the guardian’s autonomy and their right to make informed decisions about the newborn’s care.
Choice D rationale
Notifying the facility’s ethics committee about the guardian’s medication refusal is not typically necessary unless the refusal puts the newborn at significant risk and other attempts to resolve the situation have failed. In this case, the refusal of erythromycin ophthalmic ointment, while not ideal, is not likely to warrant an ethics consultation.

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Correct Answer is C

Explanation

To calculate the estimated date of delivery using Nägele’s Rule, subtract three months from the first day of the last menstrual period (August 10), and then add seven days. This gives an estimated date of delivery of May 176.

A. Insert a urinary catheter. B. Offer the client a sitz bath. C. Assist the client to the bathroom. D. Pour warm water over the client’s perineum.

Correct Answer is C

Explanation

The first action the nurse should take when caring for a client who has bladder distention following a vaginal birth is to assist the client to the bathroom. Bladder distention can occur after birth due to the pressure on the bladder during labour and birth.

Encouraging the client to empty her bladder will relieve the distention and promote comfort.

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A nurse is caring for a newborn immediately following birth who has a prescription for erythromycin ophthalmic ointment. The guardian refuses the medication. Which action should the nurse take?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is calculating the estimated date of delivery for a client who reports that the first day of her last menstrual period was August 10. Using Nägele’s Rule, which of the following is the client’s estimated date of delivery?

Correct Answer is C

Explanation

A nurse is caring for a client who has bladder distention following a vaginal birth. Which of the following actions should the nurse take first?

Correct Answer is C

Explanation

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A nurse is caring for a newborn immediately following birth who has a prescription for erythromycin ophthalmic ointment.

The guardian refuses the medication. Which action should the nurse take?