A nurse is preparing to administer 0.5% Erythromycin ophthalmic ointment to a newborn.
Which route and dose should the nurse apply?

Apply 1-2 cm ribbon from outer to inner canthus.

Apply 2-3 inch ribbon from inner to outer canthus.

Apply 1-2 cm ribbon from inner to outer canthus.

Apply 1-2 inch ribbon to upper eyelid.

Answer and Explanation

The Correct Answer is C

Choice A rationale

Applying a 1-2 cm ribbon from outer to inner canthus is incorrect because it increases the risk of contamination and infection by moving from a less clean area to a more clean area.

Choice B rationale

Applying a 2-3 inch ribbon from inner to outer canthus is incorrect because the length of the ribbon is too long and the direction is not recommended for preventing contamination.

Choice C rationale

Applying a 1-2 cm ribbon from inner to outer canthus is correct as it minimizes the risk of contamination by moving from a cleaner area to a less clean area, ensuring proper application of the ointment.

Choice D rationale

Applying a 1-2 inch ribbon to the upper eyelid is incorrect because the upper eyelid is not the recommended site for application, and the length of the ribbon is too long.

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Correct Answer is D

Explanation

Choice A rationale

The xiphoid process is not the correct anatomical landmark for measuring chest circumference in newborns. It is located at the lower end of the sternum and does not provide a consistent measurement point.

Choice B rationale

The fifth intercostal space is not used for measuring chest circumference in newborns. This space is located between the ribs and is not a reliable landmark for consistent measurements.

Choice C rationale

The sternal notch is not the correct landmark for measuring chest circumference. It is located at the top of the sternum and does not provide a consistent measurement point.

Choice D rationale

The nipple line is the correct anatomical landmark for measuring chest circumference in newborns. This method ensures that the measurement is taken at a consistent and reproducible location, providing an accurate assessment of the chest size relative to growth and development standards.

A. The infant stretches their arms out and then back in toward their body. B. The infant turns their head toward their parent’s voice. C. The infant grasps the parent’s finger when placed in the infant’s palm. D. The infant brings their hand to their mouth.

Correct Answer is D

Explanation

Choice A rationale

Stretching arms out and then back in is a common reflex in newborns known as the Moro reflex. It is not a sign of feeding readiness but rather a response to a sudden loss of support or a loud noise.

Choice B rationale

Turning the head toward a parent’s voice is a sign of auditory recognition and bonding, not necessarily feeding readiness. It indicates the infant’s ability to recognize familiar sounds.

Choice C rationale

Grasping a parent’s finger when placed in the infant’s palm is a primitive reflex known as the palmar grasp reflex. It is not related to feeding readiness but is a normal reflexive action in newborns.

Choice D rationale

Bringing their hand to their mouth is a sign of feeding readiness. This action indicates that the infant is hungry and ready to feed. It is an early cue that the baby is ready to eat.

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A nurse is preparing to administer 0.5% Erythromycin ophthalmic ointment to a newborn.Which route and dose should the nurse apply?

Nursing Test Bank

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A nurse is preparing to administer 0.5% Erythromycin ophthalmic ointment to a newborn.
Which route and dose should the nurse apply?