The charge nurse is observing a staff nurse provide care to a newborn client.
Which action by the staff nurse requires follow-up by the charge nurse?
The charge nurse is observing a staff nurse provide care to a newborn client.
Which action by the staff nurse requires follow-up by the charge nurse?
A. Suctions the client's nose first then the mouth
[79%]
B. Administers prescribed Vitamin K using a 25-gauge needle in the vastus lateralis
[11%]
C. Applies prescribed erythromycin ointment to both eyes within the first hour of birth
[5%]
D. Dries the client after delivery to prevent evaporative heat loss
[5%]
Statistics
Subject/Lesson
Subject
Maternal & Newborn Health
Lesson
Newborn
Client Need
Test Plan
Health Promotion and Maintenance
Related Topic
Ante/Intra/Postpartum and Newborn Care
Item Type
Item Type
Application
Explanation
Choice A is correct. This action requires follow-up by the charge nurse. The correct order of suctioning a newborn is mouth first, then nose. Suctioning the nose first can stimulate a gasp reflex, potentially causing the infant to aspirate secretions. This action indicates a deviation from neonatal resuscitation and safety protocols and must be corrected by the charge nurse.
Choice B is incorrect. The vastus lateralis is the recommended site for intramuscular injections in newborns. A 25-gauge needle is an acceptable size to minimize tissue trauma.
Choice C is incorrect. Prophylactic antibiotic eye ointment should be administered within the first hour of birth to prevent ophthalmia neonatorum, making this practice acceptable.
Choice D is incorrect. Newborns are at high risk for hypothermia due to heat loss via evaporation. Drying the infant promptly is an essential and evidence-based thermoregulation strategy.
Related Videos
2 Key Topics
Newborn Assessment
31.1 Immediate Newborn Evaluation
Additional Info
