A nurse is reinforcing teaching about umbilical cord care with a client who is postpartum.
Which of the following instructions should the nurse include?
Cleanse the area around the cord with baby oil each day.
Do not immerse the newborn's abdomen in water until the cord is dry.
The stump should fall off in 10 to 14 days.
Protect the cord by covering it with the newborn's diaper.
The Correct Answer is C
The correct answer is choice C: The stump should fall off in 10 to 14 days.
Choice A rationale: Cleanse the area around the cord with baby oil each day. This is incorrect because cleansing with baby oil is not recommended. Instead, the nurse should advise the client to clean the area with water and a mild soap if necessary
Choice B rationale: Do not immerse the newborn's abdomen in water until the cord is dry. This is incorrect because sponge baths are recommended until the umbilical cord falls off, and immersion in water is not strictly prohibited
Choice C rationale: The stump should fall off in 10 to 14 days. This is correct because the umbilical cord stump typically falls off within 10 to 14 days after birth
Choice D rationale: Protect the cord by covering it with the newborn's diaper. This is incorrect because the diaper should be folded down below the umbilical cord to keep it dry and exposed to air
In conclusion, the nurse should reinforce that the umbilical cord stump should fall off within 10 to 14 days after birth. It is essential to provide accurate information and instructions for proper cord care to prevent infection and promote healing
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale:
The client is experiencing symptoms that suggest hyperventilation due to paced breathing, which can lead to respiratory alkalosis. Breathing into a paper bag or cupped hand allows the client to rebreathe carbon dioxide and helps correct the alkalosis by increasing the carbon dioxide levels in the blood. This is a common intervention for clients experiencing lightheadedness and tingling in the fingers due to hyperventilation.
Choice B rationale:
Instructing the client to maintain a breathing rate no less than twice the normal rate is not appropriate in this situation. It can worsen the client's symptoms and may lead to further hyperventilation. This choice does not address the underlying problem of respiratory alkalosis.
Choice C rationale:
Having the client tuck her chin to her chest is not the correct action for these symptoms. This maneuver is typically used to relieve supraventricular tachycardia (SVT) or vagal stimulation in situations of rapid heart rate. It is not relevant to the client's lightheadedness and tingling fingers.
Choice D rationale:
Administering oxygen via nasal cannula is not indicated in this case. The client's symptoms are not suggestive of hypoxemia, but rather, they are related to respiratory alkalosis. Providing oxygen could potentially worsen the condition by reducing carbon dioxide levels further.
Correct Answer is D
Explanation
Choice A rationale:
The instruction to "cover the cord with the diaper" is incorrect. It's essential to keep the umbilical cord stump dry and exposed to air to promote healing. Covering it with a diaper can trap moisture and increase the risk of infection.
Choice B rationale:
The recommendation to "wrap the cord in petroleum jelly gauze" is not appropriate. Applying petroleum jelly or other ointments to the cord stump is not recommended, as it can also trap moisture and create an environment for bacterial growth.
Choice C rationale:
The instruction to "bathe the newborn with a washcloth until the cord stump falls off" is not the best practice. It's advisable to give sponge baths and avoid submerging the cord stump until it has completely dried and fallen off. Using a washcloth may cause unnecessary friction and irritation.
Choice D rationale:
The advice to "wash the cord daily with mild soap and water" is the correct instruction. Cleaning the cord stump with mild soap and water and then gently patting it dry with a clean cloth is a standard practice for cord care. Keeping the area clean helps prevent infection and promotes healing.
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