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.
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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Related Questions
Correct Answer is B
Explanation
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.
Correct Answer is B
Explanation
Choice A reason:
Immunization for rubella in the third trimester is not recommended because live vaccines are contraindicated during pregnancy due to the theoretical risk to the fetus.
Choice B reason:
The recommended time for rubella immunization is shortly after giving birth. This timing is advised because the vaccine contains a live virus, which could potentially harm the fetus if given during pregnancy. By waiting until after the delivery, there is no risk to the newborn, and the mother can develop immunity before any subsequent pregnancies.
Choice C reason:
While it is important for a woman to have immunity to rubella before getting pregnant, the immunization should not be given during the time she is trying to conceive. Women are advised to avoid pregnancy for at least 28 days after receiving the MMR vaccine, which includes the rubella component, due to the live virus in the vaccine.
Choice D reason:
Immunization for rubella should not be given immediately upon finding out that the client does not have immunity during the first trimester. As mentioned, live vaccines are contraindicated during pregnancy, and the immunization should be postponed until after the birth of the baby.
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