A mother expresses fear about changing her infant's diaper after he is circumcised with a clamp procedure.
What does the woman need to be taught to take care of the infant when she gets home?
Apply constant firm pressure by squeezing the penis with the fingers for at least 5 minutes if bleeding occurs.
Cleanse the penis gently with water and put petroleum jelly around the glans after each diaper change.
Cleanse the penis with prepackaged diaper wipes every 6 hours.
Wash off the yellow exudate that forms on the glans at least once every day to prevent infection.
The Correct Answer is B
Choice A rationale
Applying constant firm pressure to the penis for five minutes if bleeding occurs is an appropriate initial intervention for bleeding after a circumcision. However, it does not address the routine care needed after each diaper change to promote healing and prevent infection.
Choice B rationale
Cleansing the penis gently with water after each diaper change removes urine and stool, preventing irritation and potential infection. Applying a thin layer of petroleum jelly around the glans helps to keep the diaper from sticking to the healing circumcision site, reducing discomfort and promoting healing.
Choice C rationale
Prepackaged diaper wipes often contain fragrances and alcohol, which can irritate the sensitive skin of a newly circumcised penis and potentially delay healing or cause discomfort. Gentle cleansing with water is preferred.
Choice D rationale
The yellow exudate that forms on the glans after circumcision is a normal part of the healing process, known as granulation tissue. It should not be washed off, as this can disrupt healing and increase the risk of infection. It will typically disappear on its own over a few days.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale
A glucose reading of 58 mg/dL in a newborn is below the normal range (typically 40-60 mg/dL in the first hours of life, rising to 50-90 mg/dL). While this requires intervention to prevent hypoglycemia, other parameters might indicate a more immediate threat to the newborn's well-being.
Choice B rationale
A temperature of 97.4°F (36.3°C) is below the normal range for a newborn (typically 97.7°F to 99.5°F or 36.5°C to 37.5°C). Hypothermia in a newborn can lead to cold stress, increasing oxygen and glucose consumption, potentially leading to respiratory distress and hypoglycemia. Therefore, a low temperature requires immediate assessment and intervention to warm the newborn.
Choice C rationale
A respiratory rate of 48 breaths/minute is within the normal range for a newborn (typically 30-60 breaths/minute). While the respiratory rate should be monitored, it does not indicate an immediate critical issue in this case.
Choice D rationale
A pulse of 134 beats/minute is within the normal range for a newborn (typically 110-160 beats/minute). While the heart rate should be monitored, it does not indicate an immediate critical issue in this case. .
Correct Answer is A
Explanation
Choice A rationale
Deep tendon reflexes of +1 are hypoactive reflexes, indicating decreased neurological excitability. In preeclampsia, central nervous system irritability is a key feature, often leading to hyperreflexia, which would be documented as +2, +3, or +4. Therefore, +1 reflexes are inconsistent with preeclampsia.
Choice B rationale
3+ protein in the urine indicates significant proteinuria, which is a hallmark sign of preeclampsia. The kidneys are affected in preeclampsia, leading to increased excretion of protein in the urine.
Choice C rationale
A blood pressure of 148/98 mm Hg is elevated and falls within the diagnostic criteria for preeclampsia, which is hypertension (systolic blood pressure ≥140 mm Hg or diastolic blood pressure ≥90 mm Hg) that develops after 20 weeks of gestation along with proteinuria or other signs of end-organ damage.
Choice D rationale
Pitting sacral edema, or swelling in the sacral area that leaves a pit when pressed, is a common finding in preeclampsia due to fluid retention and increased capillary permeability.
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