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 A
Explanation
Choice A rationale:
The client is experiencing symptoms that suggest hyperventilation due to paced breathing, which can lead to respiratory alkalosis. Breathing into a paper bag or cupped hand allows the client to rebreathe carbon dioxide and helps correct the alkalosis by increasing the carbon dioxide levels in the blood. This is a common intervention for clients experiencing lightheadedness and tingling in the fingers due to hyperventilation.
Choice B rationale:
Instructing the client to maintain a breathing rate no less than twice the normal rate is not appropriate in this situation. It can worsen the client's symptoms and may lead to further hyperventilation. This choice does not address the underlying problem of respiratory alkalosis.
Choice C rationale:
Having the client tuck her chin to her chest is not the correct action for these symptoms. This maneuver is typically used to relieve supraventricular tachycardia (SVT) or vagal stimulation in situations of rapid heart rate. It is not relevant to the client's lightheadedness and tingling fingers.
Choice D rationale:
Administering oxygen via nasal cannula is not indicated in this case. The client's symptoms are not suggestive of hypoxemia, but rather, they are related to respiratory alkalosis. Providing oxygen could potentially worsen the condition by reducing carbon dioxide levels further.
Correct Answer is B
Explanation
Choice A rationale:
Quickening occurs between the first and second months of pregnancy. This statement is incorrect. Quickening is the term used to describe the first sensations of fetal movement, which usually occur between the 18th and 20th weeks of pregnancy. During the first and second months of pregnancy, the fetus is too small for the mother to feel any movement. This choice is inaccurate.
Choice B rationale:
Quickening occurs between the fourth and fifth months of pregnancy. This is the correct choice. Quickening typically occurs between the 18th and 20th weeks of pregnancy. It marks an important milestone in pregnancy when the mother can start feeling the baby's movements. This is a key point to include in teaching.
Choice C rationale:
Quickening starts soon after implantation. This statement is inaccurate. Quickening does not occur immediately after implantation. Implantation typically occurs around 6-10 days after fertilization. Quickening happens much later in pregnancy, as previously mentioned, between the fourth and fifth months.
Choice D rationale:
Quickening starts during the last weeks of pregnancy. This statement is also incorrect. Quickening is a term used to describe the first movements of the fetus, and it occurs during the second trimester of pregnancy, not during the last weeks. This choice is not accurate.
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