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.
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
Newborns are not born with fully developed immune responses. Their immune system is immature and continues to develop after birth. They rely on maternal antibodies for initial protection.
Choice B rationale
Newborns do not have a mature gut microbiome immediately after birth. The gut microbiome develops over time and is influenced by factors such as breastfeeding and exposure to the environment.
Choice C rationale
Newborns do not rely solely on their innate immune system. They receive passive immunity from maternal antibodies transferred through the placenta and colostrum, which provides initial protection against infections.
Choice D rationale
Newborns receive passive immunity through the placenta and colostrum, but their own immune system is not fully functional until several months of age. This passive immunity helps protect them from infections during the early months of life.
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.