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:
Moist skin is not typically associated with SGA newborns. Newborns, in general, may have moist skin shortly after birth due to the amniotic fluid and vernix caseosa, but this is not a distinguishing characteristic of SGA infants.

Choice b reason:
A gray umbilical cord is not a finding specifically associated with SGA. The color of the umbilical cord at birth can vary, and a gray color may indicate that the cord is drying, which is a normal process after clamping and cutting the cord.

Choice c reason:
Wide skull sutures are associated with SGA infants. SGA can be a result of intrauterine growth restriction (IUGR), which can lead to underdevelopment of the skull bones, resulting in wider-than-normal sutures. This is because the skull may not have grown to its expected size due to the growth restriction experienced by the infant.

Choice d reason:
A protruded abdomen is not typically associated with SGA infants. In fact, SGA infants may have a scaphoid or sunken abdomen due to reduced subcutaneous fat and muscle mass. A protruded abdomen in a newborn could be a sign of other conditions such as organomegaly or gastrointestinal issues.

A. The client is exhibiting early indications of mastitis. B. Additional interventions are not indicated at this time. C. The client should be advised to remove her nursing bra. D. Application of a heating pad to the breasts is indicated.

Correct Answer is B

Explanation

Choice a reason:
Mastitis is an infection of the breast tissue that results in pain, swelling, warmth, and redness. The symptoms of mastitis typically include breast tenderness, redness on the skin, breast pain, and sometimes fever and malaise. While the client's breasts are described as hard and warm, which could be associated with mastitis, the absence of other key symptoms such as fever or flu-like symptoms suggests that mastitis may not be the issue here.

Choice b reason:
Three days postpartum, it is normal for the fundus to be below the umbilicus and for lochia rubra to be present. The hardness and warmth of the breasts could be due to milk coming in, which is also a normal postpartum change. Without additional symptoms of concern, such as fever, severe pain, or signs of infection, it is reasonable to conclude that no additional interventions are required at this time.

Choice c reason:
Removing a nursing bra can provide comfort, especially if it is too tight and contributing to breast engorgement or clogged ducts. However, there is no indication that the client's nursing bra is causing an issue. Nursing bras are designed to support the breasts during breastfeeding and typically do not need to be removed unless they are causing specific problems.

Choice d reason:
Applying a heating pad can help with milk let-down and relieve discomfort from engorgement or clogged ducts. However, since the client is not exhibiting signs of mastitis or severe engorgement, and the warmth of the breasts may be due to normal postpartum changes, the application of a heating pad is not necessarily indicated at this time.

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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

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Correct Answer is C

Explanation

Correct Answer is B

Explanation

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