A nurse is assessing a postmature infant.
Which of the following findings would the nurse expect? (Select all that apply.)

Cracked, peeling skin.

Positive moro reflex.

Creases covering soles of feet.

Short soft fingernails.

Vernix in the folds and creases.

Answer and Explanation

Correct Answer : C

Choice A rationale

Applying petroleum jelly to the umbilical cord stump is discouraged as it may trap moisture, creating an environment conducive to bacterial growth. Dry cord care is preferred to reduce the risk of infection.

Choice B rationale

Washing the cord daily with soap and water is unnecessary and could lead to irritation or prolonged drying time. The cord stump requires minimal handling to promote natural healing and detachment.

Choice C rationale

Giving sponge baths ensures the cord stump remains dry, which is essential for preventing infection and expediting natural detachment. This method avoids soaking the stump, reducing the risk of maceration or bacterial colonization.

Choice D rationale

Covering the umbilical cord stump with a diaper increases moisture retention, which can delay healing. Proper diaper placement below the stump is recommended to minimize irritation and promote airflow.

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Correct Answer is A

Explanation

Choice A rationale

Massaging the fundus is the first-line intervention when the fundus is soft and spongy, indicating uterine atony. Massage stimulates uterine contractions, reducing postpartum bleeding and restoring uterine tone, which is crucial to prevent hemorrhage.

Choice B rationale

Notifying the healthcare provider is necessary if initial interventions fail to address uterine atony. However, immediate action such as massaging the fundus should be taken first to minimize bleeding risks and stabilize the client.

Choice C rationale

Documenting fundal height and consistency is important but not an immediate intervention. Recording observations without addressing the atony fails to prevent potential complications like postpartum hemorrhage, which requires prompt and active management.

Choice D rationale

Administering Oxytocin as per MD orders aids uterine contraction but is not the first intervention. Massaging the fundus provides immediate mechanical stimulation to contract the uterus, a vital step before pharmacological measures are considered.

A. I should clean the area with alcohol swabs to prevent infection. B. I will call the doctor if I see any bleeding. C. I will make sure his diaper is loose in the front. D. The Plastibell will fall off within the first 24 hours after the procedure.

Correct Answer is C

Explanation

Choice A rationale

Alcohol swabs are not recommended for cleaning the circumcision site as they may irritate the delicate tissue and delay healing. Proper care involves gentle cleansing with water and avoiding substances that can cause discomfort or tissue damage.

Choice B rationale

While monitoring for bleeding is essential, small spots of blood on the diaper may be normal. Excessive bleeding, however, is a cause for concern and should prompt immediate medical consultation, emphasizing the need to differentiate normal healing signs from complications.

Choice C rationale

A loose diaper reduces pressure on the circumcision site and prevents friction, which could cause pain or disrupt the healing process. This practice ensures the Plastibell stays in position until it detaches naturally, minimizing discomfort and promoting tissue recovery.

Choice D rationale

The Plastibell typically falls off within 5 to 8 days, not within 24 hours. Misunderstanding this timeframe can cause undue anxiety for parents or lead to premature removal attempts, which may complicate the healing process or cause injury to the site.

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A nurse is assessing a postmature infant.Which of the following findings would the nurse expect? (Select all that apply.)

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Naxlex Comprehensive Predictor Exams

A nurse is assessing the fundus of a postpartum client one day after delivery and notes that the fundus is soft and spongy.Which is the first nursing intervention to perform?

Correct Answer is A

Explanation

A nurse on a postpartum unit is giving discharge instructions to a client whose newborn had a circumcision with a Plastibell technique.Which of the following client statements indicates an understanding of circumcision care?

Correct Answer is C

Explanation

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A nurse is assessing a postmature infant.
Which of the following findings would the nurse expect? (Select all that apply.)