During the newborn admission assessment, the nurse palpates the newborn's scrotum and does not feel the testicles. Which assessment technique should the nurse perform next to verify the absence of testes?
Use a fingertip to palpate the inguinal canal for a weakening or indentation
Measure the size of the scrotal sac for length and width.
Perform transillumination of the scrotal sac to visualize shadows of the testes
Observe the urethral opening on the surface of the penis when the newborn voids
The Correct Answer is A
A. Use a fingertip to palpate the inguinal canal for a weakening or indentation:
This is a reasonable next step in assessing for undescended testes. Palpating the inguinal canal can help determine if the testes are located in the inguinal area.
B.Measure the size of the scrotal sac for length and width:
While scrotal size can be relevant in some contexts, it may not provide direct information about the presence or absence of the testes. Palpation or other methods are more specific for this purpose.
C. Perform transillumination of the scrotal sac to visualize shadows of the testes:
Transillumination involves shining light through tissues to detect structures. However, in the case of evaluating the presence of testes, palpation is usually a more direct and accurate method.
D. Observe the urethral opening on the surface of the penis when the newborn voids:
This option is unrelated to assessing the presence of testes. Observing the urethral opening is more relevant for assessing the anatomy of the penis.
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Related Questions
Correct Answer is D
Explanation
A. Chromosomal abnormalities:
While an ultrasound can sometimes identify structural abnormalities, it's not the primary tool for detecting chromosomal abnormalities. Genetic testing or procedures like amniocentesis are more specific for this purpose.
B. Sex and size of the infant:
An ultrasound is indeed used to determine the sex of the baby and assess its size and growth.
C. Lecithin-sphingomyelin ratio:
The lecithin-sphingomyelin ratio is typically assessed in tests related to fetal lung maturity, which is not the primary purpose of a routine ultrasound.
D. Fetal growth and gestational age:
This is one of the primary purposes of a routine ultrasound during pregnancy. It helps evaluate the baby's growth and ensures it aligns with the expected gestational age.
Correct Answer is B
Explanation
A. Insert a Foley catheter with a urimeter to monitor hourly output: This is a reasonable intervention because magnesium sulfate can affect renal function, and monitoring urinary output is essential. However, there's a more critical intervention to consider first.
B. Have calcium gluconate immediately available: This is the highest priority. Magnesium sulfate toxicity can lead to neuromuscular blockade, and calcium gluconate is the antidote. Having it readily available is crucial in case signs of magnesium toxicity (such as loss of deep tendon reflexes) appear.
C. Provide a quiet environment with subdued lighting: While maintaining a calm environment is generally important for clients on magnesium sulfate, it is not the highest priority in this situation.
D. Assess deep tendon reflexes (DTRs) every 4 hours: This is an important part of monitoring for magnesium sulfate toxicity. However, the immediate availability of calcium gluconate is the highest priority in case toxicity occurs.
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