A nurse is reinforcing teaching about umbilical cord care with a client who is postpartum.
Which of the following instructions should the nurse include?
Cleanse the area around the cord with baby oil each day.
Do not immerse the newborn's abdomen in water until the cord is dry.
The stump should fall off in 10 to 14 days.
Protect the cord by covering it with the newborn's diaper.
The Correct Answer is C
The correct answer is choice C: The stump should fall off in 10 to 14 days.
Choice A rationale: Cleanse the area around the cord with baby oil each day. This is incorrect because cleansing with baby oil is not recommended. Instead, the nurse should advise the client to clean the area with water and a mild soap if necessary
Choice B rationale: Do not immerse the newborn's abdomen in water until the cord is dry. This is incorrect because sponge baths are recommended until the umbilical cord falls off, and immersion in water is not strictly prohibited
Choice C rationale: The stump should fall off in 10 to 14 days. This is correct because the umbilical cord stump typically falls off within 10 to 14 days after birth
Choice D rationale: Protect the cord by covering it with the newborn's diaper. This is incorrect because the diaper should be folded down below the umbilical cord to keep it dry and exposed to air
In conclusion, the nurse should reinforce that the umbilical cord stump should fall off within 10 to 14 days after birth. It is essential to provide accurate information and instructions for proper cord care to prevent infection and promote healing
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale:
The nurse should prioritize the client's needs based on the severity of their condition. A client scheduled for discharge in 2 hours following a laparoscopic tubal ligation is generally stable and not in immediate need of care. Discharge planning can be done later.
Choice B rationale:
A client who experienced a cesarean birth 4 hours ago and reports pain requires immediate attention. Pain is a subjective symptom that should be addressed promptly to ensure the client's comfort and well-being. Uncontrolled pain can lead to complications and negatively affect the client's overall recovery.
Choice C rationale:
A client with preeclampsia and a blood pressure of 138/90 mm Hg is a concerning situation, but it is not the top priority in this scenario. Preeclampsia requires monitoring and intervention, but the client who just had a cesarean birth and is experiencing pain should be attended to first.
Choice D rationale:
A client who experienced a vaginal birth 24 hours ago and reports no bleeding is not a high-priority concern. Some clients may have minimal bleeding or none at all after a vaginal birth, and this can be normal. The absence of bleeding alone does not warrant immediate attention.
Correct Answer is B
Explanation
Choice A rationale:
Maternal/newborn blood group incompatibility can lead to jaundice in newborns, but it typically occurs within the first 24 hours of life. In this scenario, the baby is delivered 12 hours ago, and the yellowing of the skin is described as "slight.”. Physiologic jaundice, which occurs in the majority of newborns, typically appears on the second or third day after birth, so this choice is less likely.
Choice B rationale:
Physiologic jaundice is the most likely cause of the slight yellowing of the newborn's skin. It typically appears on the second or third day after birth and is related to the immature liver's inability to efficiently process bilirubin. Physiologic jaundice is a common and self-limiting condition that does not usually require treatment.
Choice C rationale:
Maternal cocaine abuse can lead to various neonatal complications, but it is not typically associated with jaundice. The yellowing of the skin in this scenario is more likely related to another cause.
Choice D rationale:
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