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 D
Explanation
A nurse is reinforcing teaching with a client who is pregnant and whose routine diagnostic testing reveals a negative rubella titer. Which of the following statements should the nurse tell the client? The correct answer is choice D: "You will need an immunization following delivery.”.
Choice A rationale:
"You had the rubella infection as a child.”. This statement is incorrect. A negative rubella titer indicates that the client is not immune to rubella. Even if the client had the infection as a child, it does not guarantee immunity for life. Immunity can wane over time, and some individuals may not have developed sufficient immunity after a natural infection.
Choice B rationale:
"I will administer the rubella immunization to you today.”. This statement is not recommended. Rubella vaccination is a live attenuated vaccine, and it is generally contraindicated during pregnancy due to the theoretical risk of transmission to the fetus. Rubella vaccination is usually recommended postpartum if the woman is not immune. The nurse should not administer the vaccine during pregnancy.
Choice C rationale:
"You are immune to rubella.”. This statement is incorrect. A negative rubella titer clearly indicates that the client is not immune to rubella. It's crucial for healthcare providers to provide accurate information to the client and ensure that appropriate immunization is administered postpartum to protect both the mother and the newborn.
Correct Answer is A
Explanation
Choice A rationale:
As mentioned in the previous question, Rho(D) immune globulin should be administered to Rh-negative pregnant clients when the newborn is Rh positive. This is essential to prevent Rh sensitization and hemolytic disease of the newborn in future pregnancies. So, if the client is Rh negative and the newborn is Rh positive, the nurse should administer Rho(D) immune globulin to prevent complications. Choice A is the correct answer.
Choice B rationale:
If both the client and the newborn are Rh positive, there is no risk of Rh incompatibility, and Rho(D) immune globulin administration is not necessary. Choice B is not the correct answer.
Choice C rationale:
When both the client and the newborn are Rh negative, there is no risk of Rh incompatibility, and therefore, Rho(D) immune globulin administration is not required. Choice C is not the correct answer.
Choice D rationale:
If the client is Rh positive and the newborn is Rh negative, there is no risk of Rh incompatibility, and Rho(D) immune globulin administration is not necessary in this scenario. Choice D is not the correct answer.
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