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.
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
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale
While assessing the station of the presenting part is important during labor, it is not the most crucial assessment following the administration of epidural anesthesia.
Choice B rationale
Monitoring maternal blood pressure is the most important assessment following the administration of epidural anesthesia. Epidural anesthesia can cause a drop in blood pressure, which can lead to complications for both the mother and the baby.
Choice C rationale
Although assessing the variability of the fetal heart rate is important during labor, it is not the most crucial assessment following the administration of epidural anesthesia.
Choice D rationale
While assessing the level of pain sensation is important to evaluate the effectiveness of the epidural anesthesia, it is not the most crucial assessment following its administration.
Correct Answer is B
Explanation
Choice A rationale
Preparing a vacuum is not the first action to take when the fetal head retracts against the perineum during the second stage of labor.
Choice B rationale
Applying suprapubic pressure can help guide the baby’s head out. This is a common practice during the second stage of labor when the baby’s head retracts against the perineum.
Choice C rationale
Applying fundal pressure is not typically done when the fetal head retracts against the perineum. Fundal pressure can be used to assist in the delivery of the baby, but it’s not the first action to take in this situation.
Choice D rationale
Preparing forceps is not the first action to take when the fetal head retracts against the perineum. Forceps are used to assist in the delivery of a baby, but only when necessary.
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