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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice a reason:
The pattern of contractions can be a sign of true labor when they are regular, frequent, and increase in intensity and duration over time. In true labor, contractions do not subside with rest or hydration and become progressively more organized. However, contractions alone can be misleading, as Braxton Hicks contractions may also present a pattern but do not lead to cervical changes.
Choice b reason:
The station of the presenting part refers to the position of the baby's head (or presenting part) in relation to the ischial spines of the mother's pelvis. While the station can indicate how far labor has progressed, it is not a definitive sign of true labor. The station changes as labor progresses, but it can also be affected by other factors such as the baby's position.
Choice c reason:
Rupture of the membranes, commonly known as water breaking, can occur before or during labor. While it is a sign that labor may be imminent, it does not confirm true labor. Some women may experience premature rupture of membranes without contractions or cervical changes.
Choice d reason:
Changes in the cervix, including effacement (thinning) and dilation (opening), are the most reliable signs of true labor. Effacement is measured in percentages, and dilation is measured in centimeters. The cervix must be 100% effaced and dilated to 10 centimeters for childbirth to occur. These changes are a direct result of true labor contractions and indicate that the body is preparing for delivery.
Correct Answer is A
Explanation
Choice a reason:
Observing for meconium in respiratory secretions is crucial for SGA newborns because they are at increased risk for meconium aspiration syndrome (MAS). MAS occurs when a newborn breathes in meconium-stained amniotic fluid into their lungs, which can cause respiratory distress. It is more common in full-term or post-term babies, and early detection and treatment are vital for improving outcomes.
Choice b reason:
Monitoring for hyperglycemia is important as SGA newborns are at risk for blood sugar imbalances. Hyperglycemia in newborns can be due to various factors, including stress, and requires careful management to prevent complications. However, it is not the primary concern immediately post-delivery for SGA newborns compared to the risk of MAS.
Choice c reason:
Monitoring for hyperthermia is less commonly a primary concern for SGA newborns immediately after birth. Hyperthermia can lead to dehydration and increase metabolic demands, which can be harmful to newborns. However, the immediate risk of hyperthermia is not as high as the risk of MAS for SGA newborns.
Choice d reason:
Identifying manifestations of anemia is important in newborn care. Anemia in newborns can present as pale skin, irritability, and a fast heart rate. While it is a condition that requires attention, the immediate post-delivery concern for SGA newborns is typically the risk of MAS rather than anemia.
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