The nurse finds that an infant admitted for surgical repair of an inguinal hernia voids a urinary stream from the ventral surface of the penis.
What action should the nurse take?

Assess for bladder distention.

Listen for bowel sounds.

Document the observation.

Check the scrotum for testicular descent.

Answer and Explanation

The Correct Answer is C

Choice A rationale
While assessing for bladder distention is important in general urinary assessment, it is not directly related to the observation of the infant voiding a urinary stream from the ventral surface of the penis.
Choice B rationale
Listening for bowel sounds is a part of the general abdominal assessment. However, it does not provide information related to the observation of the infant voiding a urinary stream from the ventral surface of the penis.
Choice C rationale
Documenting the observation is the correct action. The nurse has observed that the infant voids a urinary stream from the ventral surface of the penis. This could indicate a condition such as hypospadias, where the urethral opening is on the underside of the penis. This is an important finding that should be documented and reported.
Choice D rationale
Checking the scrotum for testicular descent is part of the general assessment of the male genitalia. However, it does not provide information related to the observation of the infant voiding a urinary stream from the ventral surface of the penis.

Nursing Test Bank

Test Bank #1: RN Pharmacology Exams Test Bank #2: RN Medical-Surgical Exams Test Bank #3: RN Fundamentals Exams Test Bank #4: RN Maternal-Newborn Exams Test Bank #5: RN Anatomy and Physiology Exams Test Bank #6: RN Obstetrics and Pediatrics Exams Test Bank #7: RN Fluid and Electrolytes Exams Test Bank #9: RN Adult Health Test Bank #10: RN Dosage Calculation Test Bank #11: RN Community Health Exams Test Bank #12: RN Psychology Exams Test Bank #13: RN Nursing Care Of Children Test Bank #14: RN Foundations of Nursing Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Exam #1: RN Comprehensive predictor 2023 proctored exam Exam #2: Ati rn vati comprehensive predictor proctored exam Exam #3: Ati Rn Comprehensive Predictor Proctored Exam 2023 Exam #4: Rn Comprehensive Predictor 2023 Proctored Exam - St. Joseph Exam #5: RN Comprehensive Predictor Proctored Exam (National U CA San Diego) Exam #6: Ati rn comprehensive predictor 2023 retake proctored exam Exam #7: RN Hesi Exit Proctored Exam Exam #8: Hesi RN Exit proctored exam Exam #9: Hesi rn exit proctored exam Exam #10: Hesi Rn compass exit B proctored exam

Free Nursing Study Resources

Correct Answer is C

Explanation

Choice A rationale

Keeping the skin incision moist by periodically wetting the dressing is not the recommended care for a myelomeningocele surgical repair. The dressing needs to be kept dry to prevent infection and promote healing.

Choice B rationale

Removing the tape rapidly from the edges of the dressing during a change is not advised. This could potentially damage the skin and disrupt the healing process.

Choice C rationale

An intact dressing protects the incision from fecal contamination, which is crucial in preventing infection. This statement indicates an understanding of the procedure.

Choice D rationale

While it’s important to keep the dressing dry to ensure easy removal of sutures, it’s not the primary concern. The main goal is to protect the incision from contamination.

A. Her vital signs are as follows: Temperature 100.4° F (38° C) orally, Heart rate 86 beats/minute, Respiratory rate 16 breaths/minute, Blood pressure 102/12 mm Hg, Pain 4 on a 0 to 10 pain scale. B. She was assisted to the bathroom where she voided 150 mL of clear yellow urine. C. Lochia rubra is moderate with small clots, no foul odor noted D. The fundus is firm at the umbilicus. E. The episiotomy edges are well approximated, with no redness, edema, drainage, or ecchymosis. F. There is no pain, redness, or swelling in the calves. G. A 1,000 mL bag of lactated Ringer’s solution containing 10 units of oxytocin is infusing via an 18-gauge peripheral IV in the left forearm at 125 mL per hour, with 500 mL remaining in the bag. H. The IV is patent, without redness or swelling, and can be discontinued when this bag’s infusion is complete.

Correct Answer is ["A","B","C","D","E","F","G","H"]

Explanation

Step 1: The patient’s vital signs are as follows: Temperature 100.4° F (38° C) orally, Heart rate 86 beats/minute, Respiratory rate 16 breaths/minute, Blood pressure 102/12 mm Hg, Pain 4 on a 0 to 10 pain scale.

Step 2: She was assisted to the bathroom where she voided 150 mL of clear yellow urine. Lochia rubra is moderate with small clots, no foul odor noted. The fundus is firm at the umbilicus. The episiotomy edges are well approximated, with no redness, edema, drainage, or ecchymosis. There is no pain, redness, or swelling in the calves.

Step 3: A 1,000 mL bag of lactated Ringer’s solution containing 10 units of oxytocin is infusing via an 18-gauge peripheral IV in the left forearm at 125 mL per hour, with 500 mL remaining in the bag. The IV is patent, without redness or swelling, and can be discontinued when this bag’s infusion is complete.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

The nurse finds that an infant admitted for surgical repair of an inguinal hernia voids a urinary stream from the ventral surface of the penis. What action should the nurse take?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is instructing the parents of a child who underwent a surgical repair of a myelomeningocele on how to change an occlusive dressing on the child’s back. Which parental statement indicates understanding of the procedure?

Correct Answer is C

Explanation

Choice A rationale

Choice B rationale

Choice C rationale

Choice D rationale

A patient was received one hour after delivering a 9 lb 1 oz (4.1 kg) female baby Exhibits Which of the following assessment findings requires immediate follow-up by the nurse?

Correct Answer is ["A","B","C","D","E","F","G","H"]

Explanation

A 3-year-old male was brought into the emergency room this morning with a sudden onset of “fast and noisy breathing”. What other symptoms is the nurse likely to note in a child diagnosed with epiglottitis?

A woman is in the second stage of labor where the fetal head has just been born and the nurse observes the immediate retraction of the head against the perineum. What action should the nurse expect to perform to assist the healthcare provider?

A patient in active labor is prescribed oxytocin 12 milliunits/min intravenously (IV). The IV bag contains 5 units of oxytocin in 500 mL of lactated Ringer’s solution. How many mL/hour should the nurse set the infusion pump to? (Enter numerical value only) .

The nurse is providing information to a parent of a six-month old about vaccinations. Which statement made by the parent should the nurse recognize as understanding the information?

A child who weighs 55 pounds receives a prescription for isoniazid 10 mg/kg/day by mouth (PO) once a day. The bottle is labeled, “Isoniazid Oral Solution, USP 50 mg per 5 mL.”. How many mL should the nurse administer? . .

An adolescent client who has successfully managed hemophilia for the past 10 years is evaluated by the nurse. Which behavior best evidences the client’s adjustment to the disorder as an adolescent?

A client who experienced a severe postpartum hemorrhage following the vaginal birth of twins is transferred to the postpartum unit. The nurse knows that assessment for which complication is the highest priority for this client?

On the first postpartum day, the nurse examines a new mother’s breasts. What condition is the nurse most likely to find?

The nurse finds that an infant admitted for surgical repair of an inguinal hernia voids a urinary stream from the ventral surface of the penis.
What action should the nurse take?