A nurse is caring for a newborn who had a circumcision 4 hr ago. During a diaper change, the nurse notes bright red blood oozing from the incision. Which of the following actions should the nurse take?
Place petroleum jelly on the bleeding site.
Secure a clean diaper snugly across the newborn's penis.
Rinse the newborn's penis with cool water.
Apply gentle pressure using a sterile dry gauze pad.
The Correct Answer is D
A. Petroleum jelly should be applied to prevent the diaper from sticking to the circumcision site, but it will not stop bleeding. Bright red blood oozing indicates that immediate action is needed to control bleeding.
B. Securing a clean diaper snugly could apply pressure but may not be the most effective method for controlling bleeding. It is more important to manage the bleeding directly by applying pressure.
C. Rinsing the newborn's penis with cool water is not an appropriate action for controlling bleeding. Cool water might be used for cleaning but does not address the issue of bleeding from the circumcision site.
D. Applying gentle pressure using a sterile dry gauze pad is the correct action to manage the bleeding. This method helps to control the bleeding by providing direct pressure to the site, which is crucial for addressing the issue.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is []
Explanation
- Potential Condition: Placenta previa
- This condition is characterized by the placenta covering the cervix, which can lead to painless, bright red vaginal bleeding during the second or third trimester.
- Actions to Take:
1. Insert a large-bore peripheral IV catheter.
- This is a precautionary measure to ensure that there is immediate venous access for fluid and blood product administration if necessary.
2. Reinforce with the client to maintain bed rest.
- Limiting physical activity can help reduce the risk of further bleeding.
- Parameters to Monitor:
1. Vaginal bleeding
- Monitoring the amount, color, and frequency of bleeding is crucial to assess the ongoing blood loss and stability of the condition.
2. Fetal well-being
- Regular monitoring of fetal heart rate and movement is important to ensure the fetus is not in distress.
Correct Answer is B
Explanation
A. Nausea is a common side effect of terbutaline but does not typically require urgent reporting. It can be managed with supportive care or adjustments in therapy.
B. Crackles in the lungs are a serious side effect of terbutaline, which can cause pulmonary edema due to fluid retention. This finding indicates a potential adverse reaction that must be reported to the provider for further evaluation and management.
C. Dizziness can occur with terbutaline use but is not as immediately concerning as other potential side effects. It may be managed by adjusting the dose or monitoring the client.
D. Tremors are a common and less severe side effect of terbutaline, typically caused by its beta-adrenergic effects. While they are uncomfortable, they are not an immediate concern compared to more severe reactions.
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