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 B

Explanation

Choice A reason:
Stimulating the infant to cry is an important action as it helps ensure that the baby's lungs are clear of fluid and are functioning properly. However, this is not the first action to take. The initial cry will often occur naturally as part of the transition from intrauterine to extrauterine life.

Choice B reason:
Clearing the respiratory tract is the priority action. Immediately after birth, it is crucial to ensure that the newborn's airway is clear to facilitate breathing. The nurse may suction the mouth and nose to remove any amniotic fluid, mucus, or other obstructions that could impede breathing.

Choice C reason:
Drying the infant off and covering the head is important to prevent heat loss, which newborns are particularly susceptible to due to their large surface area relative to body mass. However, this follows the clearance of the airway, as maintaining an open airway is the most critical initial step in newborn care.

Choice D reason:
Cutting the umbilical cord is a necessary step in the delivery process, but it is not the first action to take when caring for the newborn. The timing of cord clamping can vary, and immediate care focuses on ensuring the newborn's ability to breathe effectively.

A. "You should not receive the rubella vaccine while breastfeeding." B. "You should receive a varicella vaccine before you deliver." C. "You cannot receive the Tdap vaccine until after you deliver." D. "You can receive an influenza vaccination during pregnancy."

Correct Answer is D

Explanation

Choice A reason: The rubella vaccine is a live attenuated virus vaccine, which is generally not recommended during pregnancy due to the theoretical risk to the fetus. However, it is safe to receive the rubella vaccine while breastfeeding; it does not pose a risk to the nursing infant.

Choice B reason: The varicella vaccine, which is also a live virus vaccine, should not be administered during pregnancy because of the potential risk to the fetus. Women should be vaccinated before pregnancy or in the postpartum period.

Choice C reason: The Tdap vaccine, which protects against tetanus, diphtheria, and pertussis (whooping cough), is recommended for all pregnant women during each pregnancy, regardless of their previous history of receiving the vaccine. The optimal timing for Tdap administration is between 27 and 36 weeks of gestation to maximize the transfer of antibodies to the baby.

Choice D reason: Pregnant women are encouraged to receive the inactivated influenza vaccine at any point during their pregnancy. The flu shot is safe during pregnancy and helps protect both the mother and the baby from the flu and its complications.

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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

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Correct Answer is B

Explanation

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Correct Answer is D

Explanation

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