A nurse is caring for a newborn who has exstrophy of the bladder.
Which of the following actions should the nurse take prior to the beginning of surgical correction?
Restrict the newborn's fluid intake.
Keep the newborn in a side-lying position.
Cover the newborn's bladder with a sterile, non-adherent dressing.
Exert gentle pressure on the newborn's bladder with sterile gauze.
Exert gentle pressure on the newborn's bladder with sterile gauze.
The Correct Answer is C
A nurse caring for a newborn who has exstrophy of the bladder should cover the newborn’s bladder with a sterile, non-adherent dressing prior to the beginning of surgical correction.
Choice A is incorrect because it is not necessary to restrict the newborn’s fluid intake.
Choice B is incorrect because it is not necessary to keep the newborn in a side- lying position.
Choice D is incorrect because it is not appropriate to exert gentle pressure on
the newborn’s bladder with sterile gauze.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
If a prolapsed cord is identified, the nurse should perform a vaginal examination and ensure the presenting part is pushed upwards to relieve pressure on the cord.
Choice A) is not correct because while it is important to cover the cord with a sterile saline saturated towel if it has prolapsed externally 1, it is not the next action after calling for assistance and notifying the provider.
Choice C) is not correct because administering oxygen via non-rebreather mask at 8 L/min is not mentioned as an immediate intervention for a prolapsed cord .
Choice D) is not correct because initiating an infusion of IV fluids for the client is not mentioned as an immediate intervention for a prolapsed cord .
Correct Answer is A
Explanation
A nuchal cord occurs when the umbilical cord wraps around the fetal neck completely or for 360 degrees.
In some cases, a tight nuchal cord can cause conjunctival hemorrhage and petechiae.
Choice B) is not correct because erythema toxicum is a common rash seen in newborns and is not related to a nuchal cord.
Choice C) is not correct because periauricular papillomas are benign skin growths near the ear and are not related to a nuchal cord.
Choice D) is not correct because telangiectatic nevi, also known as stork bites or salmon patches, are common birthmarks seen in newborns and are not related to a nuchal cord.
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