RNSG 2331 - Exam 3-Capstone -1

RNSG 2331 - Exam 3-Capstone -1 Question: Which observations by the nurse indicate that a mother is protecting her two day old female newborn from infection? You answered this question Incorrectly 1. Cleans perineum from front to back after newborn soils diaper. 2. Makes certain the umbilical cord remains dry with each diaper change. 3. Places the top of the diaper just above the umbilicus. 4. Wraps sterile petroleum gauze around umbilical cord. 5. Submerges newborn in warm water up to the chest for first bath.  Rationale  Strategies 1., & 2. Correct: Cleaning from front to back will decrease the risk of infection by reducing the number of microorganisms at the urethral meatus. Keeping the umbilical cord clean and dry will decrease the risk of infection and will allow it to fall off. 3. Incorrect: The top of the diaper should be placed just below the umbilicus to prevent exposure to body waste and moisture. Placing the diaper above the umbilical cord will cause the diaper to rub the umbilicus, which will increase the risk of infection. 4. Incorrect: This would keep the umbilical cord moist and could lead to infection. Also a sterile dressing is not warranted. The umbilical cord needs to be kept dry so it will fall off. 5. Incorrect: The newborn should not be placed in water until after the umbilical cord falls off. Water submersion keeps the cord moist and at risk for infection. The umbilical cord should be kept dry so that it will fall off. Question: A client tells the nurse, “I am dying from cancer. I have told my primary healthcare provider that I do not want to be revived if my heart stops beating or I stop breathing.” What action should the nurse take first to assure that the client’s request is respected? You answered this question Incorrectly 1. Ensure a do-not-resuscitate prescription has been provided. 2. Report client wishes during the end-of-shift report. 3. Have the client sign an advanced directive. 4. Ask the client who holds the durable power of attorney for health care decisions.  Rationale  Strategies 1. Correct: The nurse should check the medical record for a DNR order. By law, a person who does not have a do-not-resuscitate (DNR) prescription, must be provided CPR in the event of a cardiac/respiratory arrest. This action will ensure the client’s endof-life wishes have been communicated and will honor the client’s wishes. 2. Incorrect: It is appropriate to report the client’s end-of-life wishes to other care givers, but not before ensuring a DNR order is in place. 3. Incorrect: If the client has advance directives, a copy should be placed in the medical record. However, a DNR prescription must also be in place to ensure the client is not resuscitated. 4. Incorrect: The client's request can be initiated by notifying the primary healthcare provider. It would be helpful for the client to have a durable power of attorney.