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 C
Explanation
Choice A rationale
Depressed fontanelles are not exclusive to premature newborns. They can occur in both premature and full-term infants and are not an indicator of prematurity.
Choice B rationale
Depressed fontanelles do not indicate infection. Infections in newborns typically present with other symptoms such as fever, irritability, and poor feeding.
Choice C rationale
Depressed fontanelles are a sign of dehydration in newborns. When a newborn is dehydrated, the fontanelles can appear sunken due to the lack of fluid in the body.
Choice D rationale
Depressed fontanelles are not a normal finding in newborns. Normally, fontanelles should be flat or slightly curved inward. A depressed fontanelle is a clinical sign that requires further evaluation and intervention.
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.