A nurse is providing care to several neonates. In giving the infants prophylactic medication to prevent ophthalmia neonatorum

Correct Answer: b

Rationale: In this scenario, the correct answer is B) Erythromycin (Eyemycin) for preventing ophthalmia neonatorum. Erythromycin is the recommended prophylactic medication for newborns to prevent this condition caused by Neisseria gonorrhoeae and Chlamydia trachomatis. Erythromycin ointment is considered more effective and less irritating than silver nitrate. Penicillin is not used for ophthalmia neonatorum prophylaxis. Educationally, understanding the rationale behind using erythromycin is crucial for nursing students as it highlights evidence-based practice in neonatal care. It also emphasizes the importance of preventing ophthalmia neonatorum, a serious eye infection that can lead to blindness if left untreated. This knowledge equips nurses with the necessary information to provide safe and effective care to newborns. It also reinforces the significance of following established protocols and guidelines in medication administration to ensure optimal patient outcomes.

Correct Answer: C

Rationale: The correct answer to the question is C) "It's very familiar to them from being in utero." This answer is correct because during their time in the womb, babies are in a flexed position due to the limited space available. This flexed position is comforting and familiar to newborns as it replicates the position they were in before birth. It helps them feel secure and safe as it mimics the environment they were used to. Option A) "Flexion keeps their limbs symmetrical" is incorrect because although flexion may contribute to keeping limbs in a more symmetrical position, the primary reason for newborns preferring flexion is the familiarity from being in utero. Option B) "It keeps their body temperature normal" is incorrect as flexion does not play a direct role in regulating body temperature in newborns. Option D) "They don't have the strength for extension" is incorrect as the preference for flexion in newborns is not due to a lack of strength for extension but rather due to the comfort and security associated with the fetal position. Understanding why newborns prefer a flexed position is crucial for healthcare professionals working with newborns as it helps them provide care and handle newborns in a way that is comforting and promotes a sense of security for the infant. By knowing this, nurses and caregivers can create a supportive environment that meets the needs of the newborn.

Correct Answer: C

Rationale: In this question regarding measuring a newborn's head circumference, the correct answer is option C) Records the largest of three measurements. This answer is correct because when measuring a newborn's head circumference, it is important to ensure accuracy by taking multiple measurements and recording the largest one. This is because newborns can be fidgety, and their heads may not be perfectly round, so taking multiple measurements helps account for any variations. Option A) Measures three times records the average is incorrect because taking the average may not capture the true size of the newborn's head if there is variability in the measurements. A single average may not accurately represent the actual head circumference. Option B) Places tape measure at the hairline is incorrect because the tape measure should be placed around the widest part of the head, usually just above the eyebrows and ears. Placing it at the hairline may lead to an inaccurate measurement. Option D) Uses two finger-breadths to estimate size is incorrect because using finger-breadths is not a precise or accurate method for measuring head circumference. It is important to use a measuring tape for accurate measurements in healthcare settings. Educationally, understanding the correct procedure for measuring a newborn's head circumference is crucial for accurate assessment of growth and development. Nurses need to ensure they follow proper techniques to obtain precise measurements, as these measurements can be important indicators of health and development in infants.

Correct Answer: C

Rationale: In this scenario, option C is the correct choice because it aligns with best practices in newborn hearing screening. The nurse should explain to the parents that a failed AABR test does not definitively indicate deafness in the newborn. It is crucial to retest the baby's hearing within a month to rule out any temporary issues or potential false results from the initial test. Option A is incorrect because it is important to avoid making definitive statements about a baby's hearing status based solely on one failed test. Option B is incorrect as it does not address the need for a retest within a specific timeframe. Option D is also incorrect as waiting a week may not be sufficient to reevaluate the baby's hearing accurately. From an educational perspective, it is essential for nurses to understand the nuances of newborn hearing screening and communicate effectively with parents regarding the significance of test results. Emphasizing the need for timely follow-up testing ensures early detection and intervention if there are any hearing concerns, ultimately supporting the newborn's overall development and well-being.

Correct Answer: A

Rationale: When the nurse assesses a swollen scrotum, it is important to determine that the scrotal sac does not contain entrapped bowel or a mass. Transillumination can determine the presence of a mass when the light directed at the scrotum does not produce a reflection. A reddish-yellow reflection indicates fluid, which will be reabsorbed on its own. The nurse should document the findings and reassure the parents. No further action is needed.