A nurse is reinforcing teaching with the parents of a newborn about caring for the umbilical cord stump. Which of the following instructions should the nurse include?

Give the newborn a sponge bath until the cord stump falls off.

Cover the cord with the diaper.

Wash the cord daily with mild soap and water.

Wrap the cord in petroleum jelly gauze.

Answer and Explanation

The Correct Answer is A

Choice A rationale:

The correct guidance includes giving the newborn sponge baths until the cord stump falls off, which helps to keep the area dry. It is essential to keep the umbilical cord stump clean and dry to prevent infection. Submerging the cord stump in water could increase the risk of infection.

Choice B rationale:

Covering the cord with the diaper is not advisable. The diaper could trap moisture around the cord stump, leading to a higher risk of infection. The cord stump should be exposed to air as much as possible to aid in drying and healing.

Choice C rationale:

Washing the cord with mild soap and water is not necessary and could introduce moisture, which should be avoided. Instead, the stump should be cleaned gently with a soft, dry cloth if it gets dirty.

Choice D rationale:

Wrapping the cord in petroleum jelly gauze is not a recommended practice. Applying petroleum jelly or other substances to the cord stump can interfere with the drying process and increase the risk of bacterial growth, leading to infection.

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Correct Answer is B

Explanation

Rooting. Choice A rationale:

The Moro reflex is a startle reflex characterized by the infant's sudden extension and abduction of the arms in response to a loud noise or sudden movement. It is not involved in the initiation of sucking and is unrelated to breastfeeding.

Choice B rationale:

The rooting reflex is a crucial reflex that helps initiate sucking in newborns. When the infant's cheek is stroked or touched, they will turn their head toward the stimulus and open their mouth, preparing for feeding. This reflex helps the infant find the mother's nipple and begin breastfeeding effectively.

Choice C rationale:

The stepping reflex is a primitive reflex observed in newborns when held upright with their feet touching a solid surface. The baby will make stepping movements, mimicking walking. However, this reflex is not related to the initiation of sucking and breastfeeding.

Choice D rationale:

The Babinski reflex is a reflex in which the big toe extends upward and the other toes fan out when the sole of the foot is stimulated. This reflex is present in newborns and disappears as the child grows older. It is not involved in the initiation of sucking.

A. Metabolic alkalosis. B. Metabolic acidosis. C. The infant is hungry. D. The infant is overstimulated.

Correct Answer is B

Explanation

A. This condition typically results from excessive loss of acid, often due to vomiting or diuretics. It is not the most likely concern in a cold environment with an infant who has been crying and kicking.

B. A cold environment can lead to nonshivering thermogenesis in newborns, where they metabolize brown fat to generate heat. This process can lead to increased lactic acid production, potentially causing metabolic acidosis. The infant's fatigue following crying and kicking may indicate that the body has expended significant energy to stay warm, making metabolic acidosis a priority concern.

C. While hunger could be a reason for crying, it is not the priority concern in this scenario where environmental cold and fatigue are present.

D. Overstimulation might cause crying, but the environmental cold and subsequent risk of metabolic acidosis are more critical concerns in this context.

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A nurse is reinforcing teaching with the parents of a newborn about caring for the umbilical cord stump. Which of the following instructions should the nurse include?

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Naxlex Comprehensive Predictor Exams

A nurse is assisting a client with breastfeeding her newborn. The nurse should explain that which of the following reflexes will initiate sucking?

Correct Answer is B

Explanation

The nurse enters the room and notices that the room feels cold. The mother says, "He has been crying and kicking and now he seems very tired.”. What is the nurse's priority concern?

Correct Answer is B

Explanation

The nurse is most concerned about which assessment finding?

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