A nurse is teaching a newborn's parent how to care for the umbilical cord stump. Which of the following instructions should the nurse include?
Apply petroleum jelly to the cord stump.
Give a sponge bath until the cord stump falls off.
Cover the cord with the diaper.
Wash the cord daily with mild soap and water.
The Correct Answer is B
Choice A reason:
Applying petroleum jelly to the umbilical cord stump is not recommended. The goal is to keep the stump dry to encourage the healing process. Petroleum jelly is a moisture barrier and could potentially keep the area too moist, which may delay the drying and falling off of the stump.
Choice B reason:
Giving sponge baths until the cord stump falls off is the correct practice. It is important to keep the stump dry, so sponge baths are preferred over tub baths during this time. This helps prevent the stump from staying wet, which can lead to infection or delayed healing.
Choice C reason:
It is not advised to cover the cord with the diaper. Instead, the diaper should be folded down away from the stump or use diapers with a special cut-out to keep the stump exposed to air. This helps the stump to dry and fall off more quickly.
Choice D reason:
Washing the cord daily with mild soap and water is not necessary and could be counterproductive. The stump should be kept dry, and if it gets dirty, it can be cleaned gently with a soft, damp cloth and then dried thoroughly. Regular bathing can introduce moisture, which may increase the risk of infection.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A reason:
Inserting an indwelling urinary catheter can be helpful in measuring urine output and reducing bladder distention, which may impede uterine contractions. However, it is not the immediate next step in managing postpartum hemorrhage.
Choice B reason:
Administering oxytocin by continuous IV infusion is a standard intervention to promote uterine contractions after delivery, which helps to control bleeding. However, before starting an oxytocin infusion, it is important to ensure that there are no retained placental fragments and that the uterus is not already well-contracted.
Choice C reason:
Massaging the client's fundus is the priority action because it can stimulate uterine contractions, which are essential for controlling postpartum bleeding. A firm, contracted uterus helps to compress the blood vessels and prevent excessive bleeding.
Choice D reason:
Tilting the client onto her right side with her legs elevated can help improve venous return and may be part of the management for shock. However, the immediate concern in a postpartum client with excessive bleeding is to manage the bleeding by promoting uterine contractions.
Correct Answer is B
Explanation
Choice A reason:
Notifying the provider of the findings is important, but it is not the immediate priority. The provider should be informed after initial measures to stabilize the client's condition have been taken.
Choice B reason:
Positioning the client with one hip elevated, also known as the lateral or left-lateral position, is the priority action. This position can help improve blood flow and potentially increase the maternal blood pressure, which is critically low at 92/54 mm Hg. It also helps to optimize uteroplacental perfusion, which is essential for the well-being of both the mother and the fetus.
Choice C reason:
Having the client void can be helpful in preventing bladder distention, which can interfere with labor progress. However, it is not the priority action when the client's blood pressure is significantly low.
Choice D reason:
Asking the client if she needs pain medication is an important part of comfort care during labor. However, addressing the client's low blood pressure is a more immediate concern to prevent potential complications for both the mother and the fetus.
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