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

Choice A Reason:

Witnessing the signature for informed consent for surgery is important but not the immediate priority. The client’s vital signs indicate potential hemodynamic instability (low blood pressure and high heart rate), which requires prompt intervention to stabilize the client before any surgical procedures can be considered.

Choice B Reason:

Initiating IV access is the priority action. This allows for the administration of fluids and medications, which is crucial in managing the client’s hemodynamic status. The client’s low blood pressure and high heart rate suggest hypovolemia, likely due to significant blood loss. Immediate IV access enables rapid fluid resuscitation and preparation for potential blood transfusions, which are essential to stabilize the client1.

Choice C Reason:

Inserting an indwelling urinary catheter is necessary for monitoring urine output, which is an important indicator of renal perfusion and overall fluid status. However, it is not the immediate priority compared to establishing IV access, which directly addresses the client’s hemodynamic instability.

Choice D Reason:

Preparing the abdominal and perineal areas is a preparatory step for potential surgical intervention. While important, it is not the immediate priority. Stabilizing the client’s condition through IV access and fluid resuscitation takes precedence to ensure the client is in a stable condition for any subsequent procedures.

Choice A reason:

Inwardly turned foot on the affected side: An inwardly turned foot, also known as metatarsus adductus, is not typically associated with developmental dysplasia of the hip (DDH). This condition is more related to foot positioning and alignment rather than hip dysplasia.

Choice B reason:

Absent plantar reflexes: The plantar reflex, also known as the Babinski reflex, is usually present in newborns and indicates normal neurological function. An absent plantar reflex is not a common finding in DDH and would more likely suggest a neurological issue.

Choice C reason:

Lengthened thigh on the affected side: In DDH, the affected thigh is often shorter, not longer, due to the displacement of the femoral head from the acetabulum. This can lead to a noticeable difference in leg length.

Choice D reason:

Asymmetric thigh folds: Asymmetric thigh folds are a common sign of DDH. When the hip is dislocated or subluxated, it can cause uneven skin folds on the thighs and buttocks. This asymmetry is a key indicator that prompts further investigation, such as an ultrasound or X-ray.