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 C

Explanation

Choice A reason:

Precipitous labor is characterized by a labor that progresses rapidly and ends within three hours of its onset. It is not typically associated with painless, bright red vaginal bleeding. This condition is more likely to present with intense, frequent contractions and a rapid change in cervical dilation. Therefore, precipitous labor is not the correct answer in this scenario.

Choice B reason:

Abruptio placentae, also known as placental abruption, is a condition where the placenta detaches from the uterus before delivery. It can cause significant maternal and fetal complications. The classic presentation includes painful bleeding, uterine tenderness, and contractions. Given that the scenario describes painless bleeding, abruptio placentae is less likely to be the correct diagnosis.

Choice C reason:

Placenta previa is a condition where the placenta covers the cervix partially or completely. The hallmark sign of placenta previa is painless, bright red vaginal bleeding, which aligns with the scenario provided. This bleeding can occur spontaneously or be triggered by intercourse or a medical exam. Placenta previa is a serious condition that can lead to maternal and fetal hemorrhage and warrants immediate medical attention. Based on the information provided, placenta previa is the most likely diagnosis for the client described.

Choice D reason:

Threatened abortion refers to vaginal bleeding that occurs in the first 20 weeks of pregnancy, which may indicate a potential miscarriage. Since the client is at 36 weeks gestation, threatened abortion is not a relevant diagnosis for late-term bleeding. Additionally, threatened abortion is often accompanied by abdominal cramping, which is not mentioned in the scenario.

A. Drink 48 to 64 ounces of water daily. B. Avoid salting foods during cooking. C. Consume 40 to 50 g of protein daily. D. Limit intake of whole grains, raw fruits, and vegetables.

Correct Answer is A

Explanation

Choice a reason:
Hydration is crucial during pregnancy, especially for those with preeclampsia. Adequate water intake helps maintain blood volume and reduce blood viscosity, which can help manage blood pressure levels. Drinking 48 to 64 ounces of water daily is recommended to support the increased blood volume needed during pregnancy and to help prevent dehydration, which can exacerbate preeclampsia symptoms.

Choice b reason:
While reducing salt intake can be beneficial for managing blood pressure, it is not necessary to completely avoid salting foods during cooking. Instead, moderation is key. Excessive salt can lead to water retention, which can worsen preeclampsia, but some salt is needed for electrolyte balance and proper body function.

Choice c reason:
Protein is an essential nutrient for fetal growth and the repair and maintenance of maternal tissues. A daily intake of 40 to 50 grams of protein is generally recommended during pregnancy. However, for those with preeclampsia, protein needs may be higher due to potential protein loss in the urine. It's important to monitor protein intake and adjust as needed under medical guidance.

Choice d reason:
Limiting the intake of whole grains, raw fruits, and vegetables is not recommended. These foods provide essential nutrients, fiber, and antioxidants that are beneficial for both maternal and fetal health. They should be included as part of a balanced diet unless there are specific dietary restrictions advised by a healthcare provider.

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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 admitting a client who is at 36 weeks gestation and has painless, bright red vaginal bleeding. The nurse should recognize this finding as an indication of which of the following conditions?

Correct Answer is C

Explanation

A nurse is completing discharge teaching to a client in her 35th week of pregnancy who has mild preeclampsia. Which of the following information about nutrition should be included in the teaching?

Correct Answer is A

Explanation

A nurse is reinforcing teaching about reducing perineal infection with a client following a vaginal delivery. Which of the following should the nurse include in the teaching? (Select all that apply.)

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