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 D

Explanation

Choice a reason:
Monitoring the heart rate is important for any newborn, but it is not the priority intervention for an SGA newborn. SGA newborns are at risk for several complications, but abnormal heart rates are not a primary concern directly related to being small for gestational age.

Choice b reason:
While monitoring weight is a part of routine newborn care and important for tracking growth and development, it is not the most immediate concern for an SGA newborn. The priority is to address potential acute complications that can arise from being small for gestational age.

Choice c reason:
Monitoring axillary temperature is important for maintaining normothermia in newborns, especially those who are SGA, as they have less subcutaneous fat and are more prone to heat loss. However, the most critical and immediate risk for SGA newborns is hypoglycemia, making blood glucose monitoring a higher priority.

Choice d reason:
SGA newborns are at increased risk for hypoglycemia due to their decreased glycogen stores. Therefore, monitoring blood glucose levels is a priority intervention. Hypoglycemia can lead to serious complications such as seizures and brain injury if not promptly identified and treated. It is essential to monitor blood glucose levels frequently and intervene as necessary to maintain them within a normal range.

A. Blunt force trauma B. Cigarette smoking C. Hypertension D. Cocaine use

Correct Answer is C

Explanation

Choice A reason: Blunt force trauma, such as from a car accident or a fall, can indeed cause placental abruption, but it is not the most common risk factor. Trauma can lead to the placenta detaching from the uterine wall, but such events are less frequent compared to other risk factors.

Choice B reason: Cigarette smoking is associated with a variety of pregnancy complications, including placental abruption. However, while smoking does increase the risk, it is not considered the most common risk factor when compared to hypertension.

Choice C reason: Hypertension is the most common risk factor for placental abruption. High blood pressure can damage the blood vessels in the uterus, leading to the placenta detaching prematurely.

Choice D reason: Cocaine use during pregnancy can lead to placental abruption because it causes the blood vessels to constrict, which can reduce blood flow to the placenta and cause detachment. While it is a significant risk factor, it is less common than hypertension in the general population.

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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?

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Naxlex Comprehensive Predictor Exams

A nurse is planning care for a newborn who is small for gestational age (SGA). Which of the following is the priority intervention the nurse should include in the newborn's plan of care?

Correct Answer is D

Explanation

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Correct Answer is C

Explanation

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