A male newborn infant has just been circumcised. The nurse checks the surgical site, expecting it to have what appearance?

Reddened with a small amount of bloody drainage.

Pink without drainage.

Reddened with a scant amount of yellow exudate.

Reddened, with copious blood.

Answer and Explanation

The Correct Answer is C

Choice A Reason:

Reddened with a small amount of bloody drainage is a common finding immediately after circumcision. However, this is not the expected appearance after the initial healing phase. The presence of bloody drainage should decrease over time, and the site should begin to show signs of healing.

Choice B Reason:

Pink without drainage is not typical immediately after circumcision. The surgical site will usually be red and may have some drainage as part of the normal healing process. A completely pink and dry site would be expected only after full healing has occurred.

Choice C Reason:

Reddened with a scant amount of yellow exudate is the expected appearance during the healing process. The yellow exudate is part of the normal healing response and should not be mistaken for infection. This exudate typically appears within the first few days after circumcision and indicates that the healing process is progressing normally.

Choice D Reason:

Reddened, with copious blood is not normal and indicates a potential complication. Copious bleeding from the circumcision site requires immediate medical attention as it may suggest an issue with clotting or a problem with the surgical site.

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Correct Answer is A

Explanation

Choice A reason:

A respiratory rate of 48 breaths per minute is within the expected reference range for a newborn. The normal respiratory rate for newborns typically falls between 30 and 60 breaths per minute. This rate ensures that the newborn is receiving adequate oxygen to support their metabolic needs and is a sign of healthy lung function.

Choice B reason:

A respiratory rate of 22 breaths per minute is below the expected reference range for a newborn. Such a low rate may indicate respiratory depression or other underlying issues that require immediate medical attention. Newborns have higher metabolic rates and smaller lung capacities, necessitating a faster breathing rate to meet their oxygen demands.

Choice C reason:

A respiratory rate of 100 breaths per minute is above the expected reference range for a newborn. This condition, known as tachypnea, can be a sign of respiratory distress or other complications such as infection, transient tachypnea of the newborn (TTN), or congenital heart defects. It is essential to monitor and address any causes of elevated respiratory rates to ensure the newborn’s well-being.

Choice D reason:

A respiratory rate of 110 breaths per minute is significantly above the expected reference range for a newborn. This extreme tachypnea is a critical indicator of severe respiratory distress or other serious conditions that require immediate medical intervention. Prompt assessment and treatment are necessary to prevent further complications and ensure the newborn’s health.

A. Vernix in the folds and creases B. Abundant lanugo C. Positive Moro reflex D. Cracked peeling skin E. Short soft fingernails

Correct Answer is ["A","C","D"]

Explanation

Choice A reason:

Vernix in the folds and creases: Vernix caseosa is a white, cheese-like substance that covers the skin of the fetus. In post-term newborns, vernix is typically absent or only present in small amounts in the folds and creases of the skin.

Choice B reason:

Abundant lanugo: Lanugo is fine, soft hair that covers the body of the fetus. It is usually shed before birth, and post-term infants typically have little to no lanugo.

Choice C reason:

Positive Moro reflex: The Moro reflex, or startle reflex, is a normal reflex for an infant when they feel as if they are falling. This reflex is present at birth and usually disappears by 4 months of age.

Choice D reason:

Cracked peeling skin: Post-term infants often have dry, cracked, and peeling skin due to prolonged exposure to amniotic fluid.

Choice E reason:

Short soft fingernails: Post-term infants usually have long fingernails, not short and soft ones.

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A male newborn infant has just been circumcised. The nurse checks the surgical site, expecting it to have what appearance?

Nursing Test Bank

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Correct Answer is A

Explanation

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Correct Answer is ["A","C","D"]

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