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 C

Explanation

Choice A rationale:

A respiratory rate of 22/min would be abnormally low for a newborn. The expected reference range for newborns is around 30-60 breaths per minute.

Choice B rationale:

A respiratory rate of 100/min would be abnormally high for a newborn. Such a high respiratory rate may indicate respiratory distress or other underlying issues and requires further evaluation.

Choice C rationale:

A respiratory rate of 48/min falls within the expected reference range for a newborn, which is around 30-60 breaths per minute. This rate suggests that the newborn's respiratory system is functioning within the normal range.

Choice D rationale:

A respiratory rate of 110/min would be abnormally high for a newborn. As mentioned earlier, the expected reference range for newborns is around 30-60 breaths per minute, making this rate concerning and necessitating further assessment.

A. Activate respiratory arrest procedures. B. Request an order for supplemental oxygen. C. Continue routine monitoring. D. Report the observation to the charge nurse immediately.

Correct Answer is C

Explanation

Choice A rationale:

Activating respiratory arrest procedures is not necessary in this situation. The newborn's respiratory rate, although slightly elevated, does not indicate respiratory arrest. Instead, such procedures are reserved for situations where the newborn has stopped breathing or is in acute respiratory distress.

Choice B rationale:

Requesting an order for supplemental oxygen may be premature. The newborn's respiration rate of 44/min, although shallow with periods of apnea, is still within the normal range for a newborn. Providing supplemental oxygen should be considered when the newborn is showing signs of significant respiratory distress or if oxygen saturation levels are low.

Choice C rationale:

The most appropriate action in this scenario is to continue routine monitoring of the newborn's respiratory rate and overall condition. Newborns often exhibit irregular breathing patterns, including periods of apnea, especially in the first few hours after birth. As long as the newborn's color, heart rate, and overall appearance are stable, routine monitoring is appropriate.

Choice D rationale:

There is no need to report the observation to the charge nurse immediately, as the newborn's respiratory rate and pattern fall within the expected range for a 12-hour-old newborn.

Reporting should be considered when there are significant deviations from the norm or if the newborn's condition deteriorates.

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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 collecting data from a newborn 1 hr after delivery. Which of the following respiratory rates is within the expected reference range for a newborn?

Correct Answer is C

Explanation

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Correct Answer is C

Explanation

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