A nurse is teaching a client who is postpartum about caring for their newborn's umbilical cord. Which of the following instructions should the nurse include?
Cover the cord with the upper edge of the diaper.
Apply petroleum jelly around the cord with every diaper change.
Report minor bleeding when the cord's stump falls off.
Wash the area around the base of the cord with water.
The Correct Answer is D
A. Cover the cord with the upper edge of the diaper: Placing the diaper below the umbilical cord stump allows air to circulate around the area, promoting drying and preventing irritation. Covering the cord stump with the upper edge of the diaper may trap moisture and increase the risk of infection.
B. Apply petroleum jelly around the cord with every diaper change: Applying petroleum jelly or any other substance to the umbilical cord stump is not recommended as it can interfere with the natural drying process. Keeping the area dry promotes quicker healing and reduces the risk of infection.
C. Report minor bleeding when the cord's stump falls off: It is normal for a small amount of bleeding to occur when the umbilical cord stump falls off. However, ongoing bleeding or excessive bleeding should be reported to the healthcare provider. Reporting minor bleeding when the stump falls off is unnecessary as it is considered a normal part of the healing process.
D. Wash the area around the base of the cord with water: Cleaning the area around the base of the cord with water helps to prevent infection and promotes healing. It is essential to keep the area clean and dry to avoid bacterial growth. Using water alone is sufficient for cleansing, and there is no need to use soap or other products that may irritate the delicate skin.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. "I will position the shoulder harness straps 3 inches above my baby's shoulders.": The shoulder harness straps should be positioned at or below the baby's shoulders, not above them, to ensure proper restraint in the event of a crash. Placing the straps too high can increase the risk of injury to the baby.
B. "I will position my baby at a 45-degree angle in the car seat.": This statement indicates an understanding of proper car seat positioning for a newborn. Newborns should be positioned at a 45-degree angle in a rear-facing car seat to keep the airway open and prevent head flopping, which can restrict breathing. This angle helps to keep the baby's head from falling forward and blocking the airway.
C. "I will turn the car seat forward-facing when my baby is 1 year old.": It is recommended to keep infants in a rear-facing car seat until they reach the maximum weight or height limit specified by the car seat manufacturer, typically around 2 years of age. Turning the car seat forward-facing prematurely increases the risk of injury to the baby's head, neck, and spine in the event of a crash.
D. "I will place the retainer clip on my baby's upper abdomen.": The retainer clip, also known as the chest clip, should be positioned at armpit level to properly secure the harness straps over the baby's shoulders. Placing the clip on the baby's upper abdomen can result in improper restraint and increase the risk of injury in a crash.
Correct Answer is A
Explanation
A. Abdominal distention: Abdominal distention is a classic sign of paralytic ileus, which is a temporary cessation of intestinal peristalsis. When peristalsis is impaired, gas and fluid accumulate in the intestines, leading to abdominal distention.
B. Watery stool: Watery stool is not typically associated with paralytic ileus. In paralytic ileus, bowel movements are usually absent or significantly reduced due to decreased or absent peristalsis, resulting in constipation rather than watery stool.
C. Dizziness: Dizziness is not a typical sign of paralytic ileus. While the underlying cause of paralytic ileus may lead to electrolyte imbalances, which can manifest as dizziness, it is not a direct symptom of paralytic ileus itself.
D. Oliguria: Oliguria, or decreased urine output, is not directly related to paralytic ileus. Paralytic ileus affects the gastrointestinal tract, leading to symptoms such as abdominal distention and constipation, but it does not directly affect urinary output.
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