A nurse is assessing a newborn following a circumcision 48 hours ago.
The nurse should identify that yellow exudate covering the newborn's glans penis indicates which of the following?

Wound infection.

Ulceration.

Exposure to urine.

Healing.

Answer and Explanation

The Correct Answer is D

Choice A rationale

Wound infection usually presents with redness, warmth, and swelling, not just yellow exudate. The presence of yellow exudate alone typically does not indicate an infection.

Choice B rationale

Ulceration would involve the breakdown of skin or tissue, which is not indicated by the presence of yellow exudate. Ulcerations are more severe and painful than normal post-circumcision healing.

Choice C rationale

Exposure to urine can cause irritation but does not typically result in yellow exudate. Proper diapering and cleaning prevent this irritation, and exudate is part of the healing process, not a result of urine exposure.

Choice D rationale

Healing is indicated by the presence of yellow exudate, which is a normal part of the healing process post-circumcision. It signifies that the glans is recovering as expected. .

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Correct Answer is A

Explanation

The nurse should identify that contractions occurring every 5 minutes require follow-up for several reasons:

Preterm Labor Risk: At 32 weeks of gestation, regular contractions every 5 minutes could indicate the onset of preterm labor. This is concerning because preterm labor can lead to preterm birth, which poses significant risks to the baby's health and development.
Frequency and Intensity: These contractions are occurring frequently (every 5 minutes) and are described as stronger than usual Braxton Hicks contractions. This frequency and the strength of the contractions are unusual for Braxton Hicks, which are typically irregular and less intense.
Effacement and Cervical Changes: Although the cervix is closed, it is 80% effaced. Effacement means the cervix is thinning, which, in combination with regular contractions, may indicate that the body is preparing for labor.
Urinary Leakage: The client also reported urinary leakage earlier in the day, which could be a sign of ruptured membranes (water breaking). This, combined with regular contractions, increases the need for careful monitoring.

A. Cool the newborn's heel prior to the procedure. B. Puncture the center of the newborn's heel. C. Cleanse the puncture site with alcohol gauze prior to the procedure. D. Administer vitamin K 30 minutes prior to each blood draw.

Correct Answer is C

Explanation

Choice A rationale

Cooling the newborn’s heel would constrict blood vessels and make it more difficult to obtain a blood sample. Warming the heel is the preferred method to increase blood flow.

Choice B rationale

Puncturing the center of the newborn’s heel is not recommended as it could cause more pain and potential injury to the bone. The puncture should be done on the outer edges of the heel.

Choice C rationale

Cleansing the puncture site with alcohol gauze is essential to reduce the risk of infection and ensure that the sample is not contaminated.

Choice D rationale

Administering vitamin K before each blood draw is unnecessary. Vitamin K is typically given as a one-time dose to prevent bleeding issues, not related to blood draw procedures.

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A nurse is assessing a newborn following a circumcision 48 hours ago.The nurse should identify that yellow exudate covering the newborn's glans penis indicates which of the following?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse on an antepartum unit is caring for a 28-year-old gravida 1 para 0 female client at 32 weeks of gestation. Exhibits Complete the following sentence by using the list of options. The nurse should identify that _______ are findings that require follow-up.

Correct Answer is A

Explanation

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Correct Answer is C

Explanation

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A nurse is assessing a newborn following a circumcision 48 hours ago.
The nurse should identify that yellow exudate covering the newborn's glans penis indicates which of the following?