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 ["A","B"]
Explanation
The correct answer is choiceA. Manual resuscitation bagandB. An advanced airway kit.
Choice A rationale:
A manual resuscitation bag is essential in pediatric emergencies to provide immediate ventilation support if the child experiences respiratory failure. Given the child’s symptoms of fast and noisy breathing, there is a risk of respiratory distress, making this equipment crucial.
Choice B rationale:
An advanced airway kit is necessary to secure the airway in case of severe respiratory distress or failure. This kit includes tools for intubation, which may be required if the child’s condition deteriorates and manual ventilation is insufficient.
Choice C rationale:
A dose of subcutaneous epinephrine is typically used for anaphylactic reactions. While it is a critical medication in emergencies involving severe allergic reactions, it is not directly related to managing respiratory distress caused by infections or other non-allergic conditions.
Choice D rationale:
The child’s favorite toy can provide comfort and reduce anxiety during medical procedures. However, it is not a critical item for the immediate management of respiratory distress or for the placement of an intravenous line.
Correct Answer is B
Explanation
Choice A rationale
Preparing a vacuum is not the first action to take in this situation. A vacuum-assisted delivery might be considered in some cases, but it’s not the immediate action when the fetal head retracts against the perineum.
Choice B rationale
Applying suprapubic pressure is the correct action. This situation describes shoulder dystocia, where the baby’s shoulder gets stuck behind the mother’s pelvic bone during delivery. Suprapubic pressure can help dislodge the baby’s shoulder and allow the delivery to proceed.
Choice C rationale
Applying fundal pressure is not recommended in this situation. Fundal pressure could potentially worsen shoulder dystocia and is generally avoided.
Choice D rationale
Preparing forceps is not the immediate action to take. Forceps may be used in some delivery situations, but in the case of shoulder dystocia, other maneuvers are tried first.
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