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 D
Explanation
A. Chart a summary of the data at the change of the shift - Documenting a summary of data at the change of shift is appropriate for communication among healthcare providers but should not be the first action. It's important to document all relevant admission data promptly and accurately.
B. Note whether the client has a living will - While documenting the client's living will status is important for their care, it's not the first action to take during admission documentation. Immediate assessment and documentation of essential data related to the client's condition and history take priority.
C. Document the client's vital signs obtained by assistive personnel - Documenting vital signs obtained by assistive personnel is appropriate, but it should not be the first action. The nurse should first conduct a comprehensive assessment and document all relevant admission data.
D. Begin charting with an evaluation of the data - This is the most appropriate action. The nurse should start by evaluating and documenting the admission data systematically and comprehensively. This includes the client's chief complaint, medical history, allergies, current medications, vital signs, physical assessment findings, and any other pertinent information. Starting with an evaluation ensures that all relevant data are captured and documented accurately.
Correct Answer is C
Explanation
A. Human papillomavirus (HPV): HPV vaccination is typically recommended for adolescents and young adults to prevent HPV infection, which can lead to cervical cancer and other related diseases. It is not typically indicated for older adults.
B. Rotavirus: Rotavirus vaccination is recommended for infants to protect against severe diarrhea caused by rotavirus infection. It is not indicated for older adults.
C. Herpes zoster: Herpes zoster vaccination, also known as the shingles vaccine, is recommended for older adults to prevent shingles, a painful rash caused by the reactivation of the varicella-zoster virus. The risk of developing shingles increases with age, and vaccination can reduce the risk and severity of the condition.
D. Diphtheria, tetanus, and acellular pertussis (DTaP): DTaP vaccination is typically administered to children to protect against diphtheria, tetanus, and pertussis (whooping cough). Tdap is the vaccine formulation recommended for adults, which includes tetanus, diphtheria, and pertussis components.
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