A nurse is observing a new mother bathing her newborn son for the first time. For which of the following actions should the nurse intervene?

The mother plans to use a cotton-tipped swab to clean the nares.

The mother leaves the yellow exudate on the circumcision site.

The mother cleans the umbilical cord with tap water.

The mother cleans the newborn's eyes from the inner canthus outwards.

Answer and Explanation

The Correct Answer is A

Choice A Reason:
Using a cotton-tipped swab to clean a newborn's nares can be dangerous. It can push debris further into the nose, cause mucosal damage, bleeding, or even introduce germs. Instead, the nurse should advise the mother to use a bulb syringe for gentle suction if necessary.

Choice B Reason:
Leaving the yellow exudate on the circumcision site is actually recommended. This exudate is part of the normal healing process and does not need to be removed. It acts as a natural barrier to infection and will clear up as the circumcision heals.

Choice C Reason:
Cleaning the umbilical cord with tap water is generally considered safe and can help keep the area clean. However, the nurse should ensure that the mother dries the area thoroughly afterward to prevent moisture from promoting bacterial growth.

Choice D Reason:
Cleaning the newborn's eyes from the inner canthus outwards is the correct technique. It prevents contamination from the outer part of the eye to the inner part and helps to clear any discharge or debris effectively.

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Correct Answer is A

Explanation

Choice a reason:
Methylergonovine is a medication used to prevent postpartum hemorrhage, which is excessive bleeding following childbirth. It works by causing the uterine muscles to contract, thereby reducing blood loss. Postpartum hemorrhage is a significant cause of maternal morbidity and mortality worldwide, and methylergonovine is one of the medications used as a prophylactic measure to manage this risk.

Choice b reason:
While postpartum infections are a concern after childbirth, methylergonovine is not used to prevent infections. Postpartum infections can occur in different parts of the body, such as the uterus (endometritis), the urinary tract, or the site of an episiotomy or cesarean section incision. Prevention of postpartum infections typically involves hygiene practices, antibiotic prophylaxis when indicated, and monitoring for signs of infection.

Choice c reason:
Thromboembolic events, which include deep vein thrombosis and pulmonary embolism, are also a risk during the postpartum period. However, methylergonovine is not used to prevent these conditions. Prevention of thromboembolic events in the postpartum period may involve the use of anticoagulants, mechanical methods such as compression stockings, and early mobilization.

Choice d reason:
Hypertension, or high blood pressure, may be observed during the postpartum period, but methylergonovine is not indicated for the prevention of hypertension. Management of postpartum hypertension typically includes antihypertensive medications and monitoring of blood pressure levels. Methylergonovine can actually cause an increase in blood pressure as a side effect, so it must be used cautiously in individuals with hypertension.

A. Encourage the client to move to the left lateral position. B. Ask the client to rate her pain. C. Assist the client to the bathroom to void. D. Encourage the client to perform Kegel exercises.

Correct Answer is C

Explanation

Choice a Reason: Encourage the client to move to the left lateral position

Moving to the left lateral position is often recommended to improve circulation and prevent compression of the vena cava by the uterus in a pregnant client. However, in the case of a boggy fundus postpartum, this position is not the primary action to be taken.

Choice b Reason: Ask the client to rate her pain

While assessing pain is important in the postpartum period, it is not the immediate action required for a boggy fundus. A boggy fundus indicates that the uterus is not contracting properly, which can lead to excessive bleeding.

Choice c Reason: Assist the client to the bathroom to void

A boggy fundus that is displaced to the right often indicates a full bladder, which can prevent the uterus from contracting effectively. Assisting the client to the bathroom to void can help the uterus contract and reduce the risk of hemorrhage.

Choice d Reason: Encourage the client to perform Kegel exercises

Kegel exercises are beneficial for strengthening the pelvic floor muscles after childbirth. However, they are not the immediate action to take for a boggy fundus postpartum

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A nurse is observing a new mother bathing her newborn son for the first time. For which of the following actions should the nurse intervene?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is preparing to administer methylergonovine IM to a client who has experienced a vaginal delivery. The nurse should explain to the client that the purpose of this medication is to prevent which of the following conditions?

Correct Answer is A

Explanation

A nurse is caring for a client who is postpartum and finds the fundus slightly boggy and displaced to the right. Based on these findings, which of the following actions should the nurse take?

Correct Answer is C

Explanation

A nurse observes that a newborn has a pink trunk and head, bluish hands and feet, and flexed extremities 5 min after delivery. He has a weak and slow cry, a heart rate of 130/min, and cries in response to suctioning. The nurse should document what Apgar score for this infant?

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