The nurse is assisting in the administration of IV vancomycin to a client who has methicillin-resistant Staphylococcus aureus (MRSA). Which of the following findings indicate an allergic reaction to the medication?

Rationale:

A. Nystagmus: Nystagmus is characterized by involuntary eye movements and is typically associated with vestibular disorders, multiple sclerosis, or congenital conditions. It is not a symptom of macular degeneration, which primarily affects the retina.

B. Astigmatism: Astigmatism is a refractive error due to an irregularly shaped cornea or lens. It is unrelated to macular degeneration, which involves degeneration of the macula—the part of the retina responsible for sharp central vision.

C. Loss of central vision: Macular degeneration leads to progressive deterioration of the macula, resulting in blurred or complete loss of central vision while peripheral vision remains intact. This is a hallmark symptom and significantly affects activities like reading and recognizing faces.

D. Client reports sharp pain: Macular degeneration does not typically cause pain. It is a painless condition, and the presence of sharp eye pain may suggest another acute ocular issue such as glaucoma or injury, not related to macular changes.

Rationale:

A. "Perform sponge baths until the baby's umbilical cord falls off.": This is the appropriate instruction because keeping the umbilical stump dry reduces the risk of infection and promotes natural detachment. Sponge baths help prevent water from soaking the cord area until it fully heals and separates.

B. "Use an alkaline soap to bathe the baby.": Alkaline soaps can irritate a newborn’s sensitive skin by disrupting the natural acidic pH balance. Mild, pH-neutral or hypoallergenic baby cleansers are recommended to maintain skin integrity.

C. "Ensure the bath water is at least 96 degrees Fahrenheit.": Bath water should be warm, around 98.6°F (37°C), which is close to body temperature. Setting a minimum like 96°F may be too low and uncomfortable, while overheating the water poses a burn risk.

D. "Apply talcum powder daily after bathing in order to prevent diaper rash.": Talcum powder is not recommended due to the risk of respiratory irritation if inhaled. Preventing diaper rash is better achieved through frequent diaper changes and the use of barrier creams.