Nursing practice questions with comprehensive rationales
NurseDive Free Nursing Practice Question
A nurse is teaching a newborn's parent to care for the umbilical cord stump. Which of the following instructions should the nurse include?
A. Cover the cord with the diaper.
Covering the cord with the diaper can increase moisture around the stump, leading to delayed cord separation and potential infection.
B. Give a sponge bath until the cord stump falls off.
Giving a sponge bath until the cord stump falls off helps to keep the area clean and dry, reducing the risk of infection.
C. Wash the cord daily with mild soap and water.
Washing the cord daily with mild soap and water is not recommended as it can increase the risk of infection and delay cord separation.
D. Apply petroleum jelly to the cord stump.
Applying petroleum jelly to the cord stump is not recommended as it can trap moisture and increase the risk of infection.
This question is an excerpt from Nurse Dive's nursing test bank - Ati N230 Exam 3 With Ngn Maternal Newborn Proctored Exam. Take the full exam now
Full Explanation
A. Covering the cord with the diaper can increase moisture around the stump, leading to delayed cord separation and potential infection.
B. Giving a sponge bath until the cord stump falls off helps to keep the area clean and dry, reducing the risk of infection.
C. Washing the cord daily with mild soap and water is not recommended as it can increase the risk of infection and delay cord separation.
D. Applying petroleum jelly to the cord stump is not recommended as it can trap moisture and increase the risk of infection.
Similar Questions
A nurse is preparing to administer oxygen via hood therapy to a newborn who was born at 30 weeks of gestation. Which of the following is an appropriate nursing action when providing care to this infant?
A. Insert an orogastric tube for decompression of the stomach.
Inserting an orogastric tube for decompression of the stomach is not indicated for a newborn receiving oxygen via hood therapy.
B. Place the newborn in Trendelenburg position.
Placing the newborn in Trendelenburg position is not appropriate and can lead to complications such as increased intracranial pressure.
C. Remove the hood every hour for 10 min to facilitate bonding.
Removing the hood every hour for 10 minutes to facilitate bonding is not appropriate as it may compromise the effectiveness of oxygen therapy and disrupt the newborn's stability.
D. Maintain oxygen saturations between 93% to 95%.
Maintaining oxygen saturations between 93% to 95% is an appropriate nursing action to ensure adequate oxygenation while avoiding the risk of oxygen toxicity.
Full Explanation
A. Inserting an orogastric tube for decompression of the stomach is not indicated for a newborn receiving oxygen via hood therapy.
B. Placing the newborn in Trendelenburg position is not appropriate and can lead to complications such as increased intracranial pressure.
C. Removing the hood every hour for 10 minutes to facilitate bonding is not appropriate as it may compromise the effectiveness of oxygen therapy and disrupt the newborn's stability.
D. Maintaining oxygen saturations between 93% to 95% is an appropriate nursing action to ensure adequate oxygenation while avoiding the risk of oxygen toxicity.
A nurse is caring for a client 2 hours after a spontaneous vaginal birth, and the client has saturated two perineal pads with blood in a 30-minute period. Which of the following is the priority nursing intervention at this time?
A. Prepare to administer oxytocic medication.
Administering oxytocic medication may be necessary to stimulate uterine contractions and control bleeding, but palpating the client's uterine fundus is the priority to assess for uterine atony or excessive bleeding.
B. Increase the client's fluid intake.
Increasing the client's fluid intake is important for hydration but does not address the immediate concern of potential postpartum hemorrhage.
C. Assist the client on a bedpan to urinate.
Assisting the client on a bedpan to urinate is important for comfort and bladder emptying but does not address the priority of assessing and managing postpartum bleeding.
D. Palpate the client's uterine fundus.
Palpating the client's uterine fundus is the priority nursing intervention to assess for uterine atony or excessive bleeding, which could indicate postpartum hemorrhage.
Full Explanation
A. Administering oxytocic medication may be necessary to stimulate uterine contractions and control bleeding, but palpating the client's uterine fundus is the priority to assess for uterine atony or excessive bleeding.
B. Increasing the client's fluid intake is important for hydration but does not address the immediate concern of potential postpartum hemorrhage.
C. Assisting the client on a bedpan to urinate is important for comfort and bladder emptying but does not address the priority of assessing and managing postpartum bleeding.
D. Palpating the client's uterine fundus is the priority nursing intervention to assess for uterine atony or excessive bleeding, which could indicate postpartum hemorrhage.
A nurse is assessing a newborn immediately following a scheduled cesarean delivery. Which of the following assessments is the nurse's priority?
A. Respiratory distress
Assessing for respiratory distress is the priority following a cesarean delivery as newborns born via cesarean section are at increased risk for respiratory complications due to potential fluid in the lungs (transient tachypnea of the newborn) or immaturity of lung function.
B. Accidental lacerations
Accidental lacerations are important to assess but are not the priority immediately following a scheduled cesarean delivery.
C. Hypothermia
Hypothermia is a concern, but assessing for respiratory distress takes precedence as it can be life-threatening if not promptly addressed.
Full Explanation
A. Assessing for respiratory distress is the priority following a cesarean delivery as newborns born via cesarean section are at increased risk for respiratory complications due to potential fluid in the lungs (transient tachypnea of the newborn) or immaturity of lung function.
B. Accidental lacerations are important to assess but are not the priority immediately following a scheduled cesarean delivery.
C. Hypothermia is a concern, but assessing for respiratory distress takes precedence as it can be life-threatening if not promptly addressed.