A nurse is teaching a newborn's parent how to care for the umbilical cord stump. Which of the following instructions should the nurse include?
Apply petroleum jelly to the cord stump.
Give a sponge bath until the cord stump falls off.
Cover the cord with the diaper.
Wash the cord daily with mild soap and water.
The Correct Answer is B
Choice A reason:
Applying petroleum jelly to the umbilical cord stump is not recommended. The goal is to keep the stump dry to encourage the healing process. Petroleum jelly is a moisture barrier and could potentially keep the area too moist, which may delay the drying and falling off of the stump.
Choice B reason:
Giving sponge baths until the cord stump falls off is the correct practice. It is important to keep the stump dry, so sponge baths are preferred over tub baths during this time. This helps prevent the stump from staying wet, which can lead to infection or delayed healing.
Choice C reason:
It is not advised to cover the cord with the diaper. Instead, the diaper should be folded down away from the stump or use diapers with a special cut-out to keep the stump exposed to air. This helps the stump to dry and fall off more quickly.
Choice D reason:
Washing the cord daily with mild soap and water is not necessary and could be counterproductive. The stump should be kept dry, and if it gets dirty, it can be cleaned gently with a soft, damp cloth and then dried thoroughly. Regular bathing can introduce moisture, which may increase the risk of infection.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A reason:
Nausea can be a common side effect of many medications and does not necessarily indicate toxicity. While it can be uncomfortable for the patient, nausea alone, without other symptoms, is not typically a sign of magnesium sulfate toxicity.
Choice B reason:
Drowsiness is another side effect that can occur with various medications and medical conditions. It may be a symptom of magnesium sulfate toxicity, especially if it is severe or combined with other symptoms, but on its own, it is not a definitive indicator of toxicity.
Choice C reason:
Facial flushing can be a reaction to medication, including magnesium sulfate, and may occur even at therapeutic levels. It is not usually a sign of toxicity unless accompanied by more serious symptoms.
Choice D reason:
Respiratory depression is a serious and potentially life-threatening condition that can indicate magnesium sulfate toxicity. It is characterized by a decrease in the ability to breathe and a drop in oxygen levels. This is a critical finding that requires immediate medical attention and intervention.
Correct Answer is A
Explanation
Choice a reason:
Methylergonovine is a medication used to prevent or control postpartum hemorrhage by contracting the uterus. However, it is contraindicated in patients with hypertension, as it can further increase blood pressure. Given that the client's blood pressure is already elevated at 146/94 mm Hg, administering methylergonovine could pose a risk. Therefore, this prescription requires clarification from the provider before administration.
Choice b reason:
Inserting an indwelling urinary catheter can be a standard procedure after vaginal birth if the client is unable to void or if accurate measurement of urine output is needed. This does not require clarification unless there are specific contraindications or the client's condition does not warrant it.
Choice c reason:
Obtaining a laboratory study of prothrombin and partial thromboplastin time is a common practice to assess the blood's clotting ability, especially if there is a concern for bleeding disorders or if the client is at risk for postpartum hemorrhage. This prescription is clear and does not require further clarification.
Choice d reason:
Administering oxygen by nonrebreather mask at 5 L/min may be indicated if the client is showing signs of respiratory distress or hypoxia. The client's current respiratory rate is within normal limits, but if there are concerns about oxygenation, this intervention would be appropriate.
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