A nurse is teaching a newborn’s parent to care for the umbilical cord stump. Which of the following instructions should the nurse include?
Wipe the cord daily with alcohol prep pads.
Keep the cord moist.
Fold the top of the diaper underneath the cord.
Apply petroleum jelly to the cord stump.
The Correct Answer is C
Choice A rationale
Wiping the cord daily with alcohol prep pads is not recommended. Current guidelines suggest keeping the cord clean and dry without the use of alcohol, as it can delay the natural drying and falling off process.
Choice B rationale
Keeping the cord moist is not recommended. The cord should be kept dry to promote natural drying and separation. Moisture can increase the risk of infection.
Choice C rationale
Folding the top of the diaper underneath the cord is recommended to keep the cord exposed to air and prevent irritation from urine or stool. This helps the cord dry out and fall off naturally.
Choice D rationale
Applying petroleum jelly to the cord stump is not recommended. The cord should be kept dry, and the use of ointments or creams can interfere with the natural drying process. .
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Correct Answer is A
Explanation
Choice A rationale
Given the neonate’s symptoms and critically low blood glucose level (30 mg/dL), the most urgent action is to address the hypoglycemia. Therefore, the nurse shouldadminister a bolus of intravenous glucose (Option A). This immediate intervention is crucial to stabilize the neonate and prevent further complications associated with hypoglycemia.
Choice B rationale
While monitoring blood glucose levels is important, waiting 30 minutes to reassess without immediate intervention could allow the hypoglycemia to worsen, potentially leading to severe complications such as seizures or brain damage. Immediate treatment is necessary to stabilize the neonate.
Choice C rationale
Although feeding can help increase blood glucose levels, the neonate’s current symptoms (jitteriness, poor feeding, weak cry, and irritability) suggest that they may not be able to effectively feed. Additionally, the blood glucose level is critically low and requires more rapid correction than feeding alone can provide.
Choice D rationale
While maintaining an appropriate body temperature is important, the neonate’s temperature (36.1°C) is not critically low. The primary concern here is the hypoglycemia, which needs to be addressed immediately. Placing the neonate under a radiant warmer does not directly address the low blood glucose level.
Correct Answer is D
Explanation
Choice A rationale
Hyperbilirubinemia, or high levels of bilirubin in the blood, can occur in newborns of diabetic mothers due to increased red blood cell breakdown. However, it is not the primary concern immediately after birth. The priority is to address conditions that can cause immediate harm, such as hypoglycemia.
Choice B rationale
Hypomagnesemia, or low magnesium levels, can occur in newborns of diabetic mothers, but it is not the most critical issue. Magnesium levels can be monitored and corrected if necessary, but hypoglycemia poses a more immediate threat to the newborn’s health.
Choice C rationale
Hypocalcemia, or low calcium levels, can also occur in newborns of diabetic mothers. While it is important to monitor and manage calcium levels, hypoglycemia is a more urgent concern because it can lead to severe complications if not addressed promptly.
Choice D rationale
Hypoglycemia, or low blood sugar levels, is the most critical concern for newborns of diabetic mothers. These newborns are at high risk for hypoglycemia due to the high levels of insulin they produce in response to their mother’s elevated blood glucose levels during pregnancy. Hypoglycemia can cause serious complications, including seizures and brain damage, if not treated immediately.