A nurse is providing teaching to a client who reports that her baby has yellow discharge forming at the circumcision site. Which of the following is an appropriate response by the nurse?
"I will need to obtain a sample of the discharge for laboratory testing.".
"Apply povidone-iodine solution twice daily to the circumcision site.".
"Wipe the discharge away gently with a washcloth and warm water for the next 48 hours.".
"The discharge is common during the first 24 to 72 hours following a circumcision.".
The Correct Answer is D
Choice A rationale:
The nurse does not need to obtain a sample of the discharge for laboratory testing at this point. Yellow discharge after circumcision is common and generally not a cause for immediate concern. Laboratory testing is not necessary for routine circumcision care.
Choice B rationale:
Applying povidone-iodine solution twice daily to the circumcision site is not recommended in this situation. Povidone-iodine may cause irritation and delay the natural healing process.
Generally, no specific cleaning solution is required for circumcision care unless otherwise indicated by a healthcare provider.
Choice C rationale:
Wiping the discharge away gently with a washcloth and warm water for the next 48 hours is not the most appropriate action. The circumcision site should be kept clean and dry, but actively wiping away the discharge may cause irritation and disrupt the natural healing process.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A rationale:
Fresh citrus fruits are not a good source of vitamin B12. They are rich in vitamin C but do not contain vitamin B12.
Choice B rationale:
Brown rice is not a good source of vitamin B12. While it is a nutritious grain, it does not contain vitamin B12.
Choice C rationale:
Raw carrots are not a good source of vitamin B12. Carrots provide essential nutrients but do not contain vitamin B12.
Choice D rationale:
Fortified soy milk is the correct choice as it is a suitable option for someone on a vegan diet looking to increase their vitamin B12 intake. Many brands of soy milk are fortified with vitamin B12, making it a reliable source for vegans. Vitamin B12 is essential for nerve function and red blood cell production, making it especially important during pregnancy.
Correct Answer is C
Explanation
The correct answer is choice c. One acceleration of the FHR within a 20-min period.
Here's the rationale for each choice:
Choice A: Rationale: A non-stress test (NST) is supposed to assess fetal well-being by looking for accelerations in the fetal heart rate (FHR) in response to fetal movement. An FHR that peaks 20 beats above the baseline is a desirable finding in an NST, indicating good fetal reactivity.
Choice B: Rationale: While not typical during a standard NST, three uterine contractions within a 20-minute period might not necessarily require immediate intervention. However, the nurse should document it and notify the healthcare provider for further assessment, especially if the contractions are causing discomfort or if there are other concerning signs.
Choice C: Rationale: A single acceleration of the FHR within a 20-minute NST is considered non-reactive and may indicate fetal compromise. This finding requires further investigation by the healthcare provider, potentially including additional monitoring or interventions.
Choice D: Rationale: Uterine contractions lasting 20 to 30 seconds each are not a typical finding during an NST, but they may not necessarily be a cause for immediate concern unless they are causing the client pain or are accompanied by other concerning signs. The nurse should document the contractions and notify the healthcare provider.
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