Nokea
What will the nurse's instructions for a new mother to care for the infant's umbilical cord include?
- A. Keeping the area covered with a sterile dressing
- B. Dressing the stump with antibiotic ointment at every diaper change
- C. Fastening the diaper low to allow for air circulation
- D. Giving the newborn a daily tub bath until the cord falls off
Correct Answer: C
Rationale: Diaper placement below the umbilical stump allows for drying by air circulation.
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What instruction should the nurse teach the postpartum woman about perineal self-care?
- A. Perform perineal self-care at least twice a day.
- B. Cleanse with warm water in a squeeze bottle from front to back.
- C. Remove perineal pads from the rectal area toward the vagina.
- D. Use cool water to decrease edema of the perineum.
Correct Answer: B
Rationale: Cleansing from front to back prevents contamination from the rectal area.
The nurse is giving a shower to a patient who had a cesarean section 2 days previously. What interventions should be included before, during, and after the shower? (Select all that apply.)
- A. Leave abdominal dressing open to air.
- B. Position patient with back to water stream.
- C. Cover infusion site with rubber glove.
- D. Provide a shower chair.
- E. Confirm ambulation ability.
Correct Answer: B,C,D,E
Rationale: The patient should be evaluated for ambulatory ability, and the abdominal dressing and infusion site should be covered with a waterproof cover. The patient should be provided a shower chair and positioned with her back to the water stream.
The nurse is instructing a woman at 6 months postpartum on weaning her infant from breastfeeding. What interventions will the nurse suggest? (Select all that apply.)
- A. Omit newborn's favorite feeding first.
- B. Eliminate one feeding at a time.
- C. Expect the need for comfort feeding.
- D. Formula will need to be provided to substitute for feeding.
- E. Pump breasts in place of eliminated feeding.
Correct Answer: B,C,D
Rationale: When weaning a newborn from breastfeeding, the mother should eliminate the favorite feeding last. One feeding should be eliminated at a time, and the need for comfort feeding should be expected. In younger infants formula will need to be substituted. The mother should not be instructed to pump in place of eliminated feeding or the breasts will continue to produce milk.
What should the nurse's first action be when postpartum hemorrhage from uterine atony is suspected?
- A. Teach the patient how to massage the abdomen and then get help.
- B. Start IV fluids to prevent hypovolemia and then notify the registered nurse.
- C. Begin massaging the fundus while another person notifies the physician.
Correct Answer: C
Rationale: Massaging the fundus is the immediate action to stimulate uterine contractions and control bleeding, while another person notifies the physician for further management.
A woman has given birth to an unresponsive newborn that NICU staff are attempting to revive. The patient and her husband are grief stricken and request the child be baptized immediately. What is the nurse's most appropriate action?
- A. Contact the hospital chaplain.
- B. Request the couple's clergy.
- C. Baptize the newborn.
- D. Ask the physician to baptize the newborn.
Correct Answer: C
Rationale: If the condition of a newborn is poor, the parents may wish to have a baptism performed. In an emergency, the nurse may perform the baptism by pouring water on the infant's forehead while saying, 'I baptize you in the name of the Father, and of the Son, and of the Holy Spirit.'