Page 815 - Saunders Comprehensive Review For NCLEX-RN

b. While a 2-vessel cord (1 artery, 1 vein)
may present no problems or concerns,
there is a higher correlation to
intrauterine growth restriction (IUGR)
and genetic or chromosomal problems.
c. Small, thin cord may be associated with
poor fetal growth.
d. Assess for intact cord and ensure that
the cord clamp is secured.
e. Cord should be clamped for at least the
first 24 hours after birth; clamp can be
removed when the cord is dried and
occluded and is no longer bleeding.
f. Note any bleeding or drainage from the
cord.
g. Cleansing of the cord needs to be done;
hospital protocol and PHCP’s
preference determine the frequency,
technique, and skin preparation used
for cord care.
h. If signs of infection, such as moistness,
oozing, discharge, and a reddened
base, occur, antibiotic treatment is
prescribed.
2. Gastrointestinal
a. Monitor cord for meconium staining.
b. Assess for umbilical hernia.
c. Assess for abdominal depression
associated with diaphragmatic hernia.
d. Assess for abdominal distention
associated with obstruction, mass, or
sepsis.
e. Monitor bowel sounds (present within
the first hour after birth).
3. Anus
a. Ensure that the anal opening is present.
b. First stool meconium should pass
within first 24 hours.
M. Genitals
1. Female
a. Labia may be swollen; clitoris may be
enlarged.
b. Smegma may be present (thick, white
mucus discharge).
c. Pseudomenstruation, caused by the
withdrawal of the maternal hormone
estrogen, is possible (blood-tinged
mucus).

815