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

Choice A rationale
Contractions feeling further apart is not a direct indicator of the effectiveness of the hands-and-knees position in relieving discomfort associated with a fetus in the occipitoposterior position.
Choice B rationale
Feeling relief from pelvic pressure may not directly indicate the effectiveness of the hands-and-knees position in relieving discomfort associated with a fetus in the occipitoposterior position.
Choice C rationale
Improvement in back labor is a direct indicator of the effectiveness of the hands-and-knees position in relieving discomfort associated with a fetus in the occipitoposterior position.
Choice D rationale
Lessening of suprapubic pain may not directly indicate the effectiveness of the hands-and-knees position in relieving discomfort associated with a fetus in the occipitoposterior position.

A. Administer Oxytocin to the client B. Massage the client’s fundus C. Provide oxygen to the client via non-rebreather face mask D. Empty the client’s bladder

Correct Answer is B

Explanation

Choice A rationale
Administering Oxytocin to the client is an important intervention for postpartum hemorrhage, but it is not the first action the nurse should take. Oxytocin stimulates uterine contractions which can help control bleeding, but it should be administered after the initial steps of assessing the uterus and ensuring it is firm.
Choice B rationale
Massaging the client’s fundus is the priority action to address excessive vaginal bleeding. A firm, well-contracted uterine fundus often helps to control postpartum bleeding. If the uterus is not well contracted, gentle massage is often sufficient to stimulate contractions. If the uterus does not respond to massage, then further interventions such as administering Oxytocin may be necessary.
Choice C rationale
Providing oxygen to the client via a non-rebreather face mask is an intervention that might be necessary if the client shows signs of hypoxia or shock as a result of the bleeding. However, it is not the first action that should be taken.
Choice D rationale
Emptying the client’s bladder is important as a distended bladder can displace the uterus and interfere with contractions, leading to increased bleeding. However, this is not the first action to take.

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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

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Correct Answer is C

Explanation

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Correct Answer is B

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?