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.

Answer and Explanation

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.

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Correct Answer is A

Explanation

Choice A reason: When a client in active labor presents with hypotension, as indicated by a blood pressure reading of 82/52 mm Hg, the priority nursing intervention is to assist the client to turn onto her side. This position helps to alleviate pressure on the inferior vena cava, which can be compressed by the gravid uterus, thereby improving venous return and increasing blood pressure. It also enhances uteroplacental perfusion, providing better oxygenation to the fetus.

Choice B reason: While preparation for a cesarean birth may be necessary if there are signs of fetal distress or if the hypotension does not resolve, it is not the first-line intervention for isolated hypotension without other indications.

Choice C reason: Preparing for an immediate vaginal delivery is not the priority action in response to hypotension. The focus should be on stabilizing the mother's blood pressure to ensure safe delivery, whether vaginal or cesarean.

Choice D reason: Assisting the client to an upright position is not advisable in the case of hypotension, as this can further decrease venous return to the heart and exacerbate the low blood pressure.

A. "In most cases, it only lasts until the 12th week, but it will continue if you have poor bladder tone." B. "It is a minor inconvenience, which you should ignore." C. "There is no way to predict how long it will last in each individual client." D. "It occurs during the first trimester and near the end of the pregnancy."

Correct Answer is D

Explanation

Choice A reason:
Urinary frequency typically begins early in pregnancy due to hormonal changes and increased blood volume leading to more fluid being processed by the kidneys and ending up in the bladder. While it often improves in the second trimester as the uterus rises into the abdominal cavity, poor bladder tone is not typically cited as a reason for its continuation.

Choice B reason:
While urinary frequency can be seen as a minor inconvenience, it should not be ignored. It is a normal physiological change during pregnancy. However, if it is accompanied by pain, burning, or any other symptoms, it could indicate a urinary tract infection, which requires medical attention.

Choice C reason:
There is some predictability to urinary frequency in pregnancy. It often starts in the first trimester, improves in the second, and may return in the third trimester as the growing baby and uterus exert pressure on the bladder.

Choice D reason:
This choice is accurate. Urinary frequency is common in the first trimester due to hormonal changes and the growing uterus pressing on the bladder. It often returns in the third trimester when the baby "drops" and the head presses on the bladder. This is a normal part of pregnancy and usually does not indicate any complications.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who is at 40 weeks of gestation and is in active labor. The client has 6 cm of cervical dilation and 100% cervical effacement. The nurse obtains the client's blood pressure reading as 82/52 mm Hg. Which of the following nursing interventions should the nurse perform?

Correct Answer is A

Explanation

A nurse in a prenatal clinic is caring for a client who is at 7 weeks of gestation. The client reports urinary frequency and asks if this will continue until delivery. Which of the following responses should the nurse make?

Correct Answer is D

Explanation

A nurse is caring for a newborn who is small for gestational age (SGA). Which of the following findings is associated with this condition?

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A nurse in the nursery is caring for a newborn. The grandmother of the newborn asks if she can take the newborn to the mother's room. Which of the following is an appropriate response by the nurse?

A nurse is caring for a client who experienced a vaginal delivery 12 hours ago. When palpating the client's abdomen, at which of the following positions should the nurse expect to find the uterine fundus?

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