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 B
Explanation
Choice A reason:
The left lower quadrant is not typically where fetal heart tones are auscultated when the round, firm part of the fetus (usually the head) is palpated in the fundus and the long smooth surface (indicative of the back) is on the right side. Fetal heart tones are best heard through the back of the fetus, and in this position, the back is not located in the left lower quadrant.
Choice B reason:
The right upper quadrant is the correct location to auscultate fetal heart tones in this scenario. The Leopold's maneuvers suggest that the fetus is in a cephalic presentation with its back facing the right side of the mother's abdomen. Therefore, the fetal heart tones are most likely to be heard in the right upper quadrant, just below the level of the fundus.
Choice C reason:
The right lower quadrant is generally not the area to auscultate fetal heart tones if the fetus's back is on the right side and the head is in the fundus. The heart tones are typically higher up and closer to where the back is palpated.
Choice D reason:
The left upper quadrant would not be the correct place to find fetal heart tones given the described position of the fetus. With the back on the right side, auscultation on the left would not yield the clear heart tones expected.
Correct Answer is A
Explanation
Choice a) reason: Pelvic pain is a common symptom of endometritis. The pain is typically located in the lower abdomen and may be associated with uterine tenderness upon physical examination. This symptom, especially when combined with other signs such as fever and foul-smelling lochia, strongly suggests the need for further evaluation for endometritis.
Choice b) reason: Hematuria, or blood in the urine, is not a typical symptom of endometritis. While it could be a sign of other postpartum complications, such as urinary tract infections or bladder injury during childbirth, it does not directly indicate endometritis.
Choice c) reason: A localized area of breast tenderness is more indicative of a breast infection, such as mastitis, especially if associated with breastfeeding. It is not a symptom of endometritis, which affects the uterus and not the breasts.
Choice d) reason: While foul-smelling lochia can be a sign of endometritis, the key is the presence of a foul odor. A moderate amount of dark red lochia alone, without a foul odor, is a normal finding in the immediate postpartum period. It's the transition from rubra (red) to serosa (pink/brown) to alba (yellow/white) that is expected as the uterus heals.
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