The nurse is providing discharge instructions to new parents about the care of their newborn.
Which statement by the nurse provides appropriate education regarding the newborn's umbilical cord?
Report any redness or foul odor to your pediatrician.
It usually takes about a month for the cord to fall off.
Keep the diaper over the cord to protect it from clothing.
Make sure to keep the cord moist at all times.
The Correct Answer is A
Umbilical cord care focuses on preventing infection and promoting natural desiccation. Nurses apply principles of aseptic technique and health promotion to educate parents on identifying omphalitis and maintaining the cord site until the stump naturally separates from the neonate's abdomen.
Choice A rationale
Redness, edema, or foul smelling drainage are cardinal signs of omphalitis, a potentially serious infection. Parents must be taught to monitor the site closely and report these findings immediately to ensure prompt medical evaluation and antibiotic treatment.
Choice B rationale
The umbilical cord typically undergoes dry gangrene and falls off within 7 to 14 days after birth. Telling parents it takes a month is inaccurate and may cause unnecessary concern or delay the identification of delayed cord separation.
Choice C rationale
The diaper should be folded down below the umbilical stump. Keeping the cord outside the diaper prevents contamination from urine or feces and allows air exposure, which facilitates the drying process necessary for the cord to fall off.
Choice D rationale
The cord must be kept clean and dry to promote healing and separation. Moisture at the site encourages bacterial growth and delays the drying process. Current evidence based practice emphasizes dry cord care over the application of various liquids..
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["B","C","D"]
Explanation
This clinical scenario describes shoulder dystocia indicated by the turtle sign. Management requires immediate obstetric maneuvers to resolve the obstruction. Knowledge of emergency protocols, including McRoberts maneuver and suprapubic pressure, is essential to prevent fetal asphyxia and maternal trauma during delivery.
Choice A rationale
Fundal pressure is strictly contraindicated in cases of shoulder dystocia because it can further impact the anterior fetal shoulder against the maternal symphysis pubis. This action increases the risk of uterine rupture and severe brachial plexus injury.
Choice B rationale
Suprapubic pressure helps dislodge the impacted anterior shoulder by pushing it under the maternal symphysis pubis. This manual maneuver decreases the fetal bisacromial diameter, allowing the shoulder to rotate and pass through the pelvic outlet during the delivery.
Choice C rationale
Flexing the thighs toward the ears, known as the McRoberts maneuver, flattens the sacral promontory and increases the pelvic inlet diameter. This postural change facilitates the passage of the fetal shoulder and is often the first-line intervention.
Choice D rationale
Shoulder dystocia is a high-risk obstetric emergency that necessitates a multidisciplinary team approach. Calling for help ensures that neonatal resuscitation teams, anesthesia, and additional nursing staff are available to assist with complex maneuvers and provide immediate care.
Choice E rationale
While a cesarean birth is a major surgical procedure, it is typically not the immediate step once the head is delivered. Rescuers first attempt maneuvers to deliver the body vaginally, as reversing the delivery process is extremely difficult and dangerous.
Correct Answer is B
Explanation
The assessment of postpartum hemorrhage requires differentiating between uterine atony and other sources of bleeding. When the fundus remains firm despite heavy lochia saturation, nurses must apply knowledge of cervical or vaginal lacerations and prioritize immediate medical notification for intervention.
Choice A rationale
Fundal massage is the primary intervention for uterine atony, characterized by a soft or boggy uterus. Since the assessment reveals a firm fundus at the umbilicus, massage is unnecessary and will not address the source of the bleeding.
Choice B rationale
Satiating a pad in 15 minutes is a sign of severe postpartum hemorrhage. A firm fundus suggests the bleeding is likely from a laceration rather than atony. Rapid notification of the provider is essential for surgical repair.
Choice C rationale
Oxytocin is a uterotonic medication used to stimulate uterine contractions and manage hemorrhage caused by atony. Because the fundus is already firm, administering oxytocin is inappropriate and will not resolve bleeding originating from a suspected tissue tear.
Choice D rationale
Assisting the client to the restroom helps empty the bladder, which can resolve a displaced, boggy fundus. However, with a firm fundus and rapid blood loss, this delays critical care and poses a fainting risk for the client.
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