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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?

A.

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

B.

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

C.

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

D.

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

An apical pulse rate of 124 bpm is within the normal range for a neonate (110-160 bpm). There is no need to ask another nurse to verify the heart rate as it is not an abnormal finding.

Choice B rationale

Calling the provider for an apical pulse rate of 124 bpm is unnecessary as it is within the normal range for a neonate. This action would be appropriate if the heart rate were significantly outside the normal range.

Choice C rationale

Preparing the newborn for transport to the NICU for an apical pulse rate of 124 bpm is not warranted. The heart rate is within the normal range, and there is no indication for further cardiac observation.

Choice D rationale

Documenting the expected finding is the appropriate action. An apical pulse rate of 124 bpm is within the normal range for a neonate, and no further action is needed.

Correct Answer is B

Explanation

Choice A rationale

Small for gestational age (SGA) refers to newborns whose birth weight is below the 10th percentile for their gestational age.

Choice B rationale

Appropriate for gestational age (AGA) refers to newborns whose birth weight is between the 10th and 90th percentiles for their gestational age. A newborn weighing 3350 g at 39 weeks gestation falls within this range.

Choice C rationale

Low birth weight is defined as a birth weight of less than 2500 g, which does not apply to this newborn.

Choice D rationale

Large for gestational age (LGA) refers to newborns whose birth weight is above the 90th percentile for their gestational age.

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