The nurse is caring for a newborn who was circumcised using a Gomco clamp 12 hours ago and notes that there is a small amount of blood on his diaper where his penis rests against it.
The most appropriate nursing action would be to:
Apply gentle pressure to stop bleeding
Change his diaper more frequently
Document this as a normal finding
Notify his physician
The Correct Answer is C
The correct answer is choice C. Document this as a normal finding. According to the American Academy of Family Physicians, bleeding from the dorsal slit after circumcision using a Gomco clamp is usually minimal and will stop once the clamp is in place.
Therefore, a small amount of blood on the diaper 12 hours after the procedure is not a cause for concern and does not require any intervention.
Choice A is wrong because applying gentle pressure to stop bleeding is not necessary and may cause more trauma to the wound.
Choice B is wrong because changing the diaper more frequently may also disturb the healing process and increase the risk of infection. Choice D is wrong because notifying the physician is not indicated unless there is excessive or persistent bleeding, signs of infection, or other complications.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
The correct answer is choice B. Washing the penis with soap and water daily can irritate the circumcision site and delay healing.
The parents should only use warm water to gently clean the area and pat it dry.
They should avoid using soap, alcohol, or peroxide on the wound.
Choice A is wrong because changing the diaper every 3 to 4 hours is recommended to prevent infection and keep the area clean and dry.
Choice C is wrong because applying petroleum jelly on the penis with each diaper change can protect the wound from sticking to the diaper and reduce friction.
Choice D is wrong because calling the doctor if they see any signs of infection, such as redness, swelling, pus, foul odor, or fever, is a correct action.
Correct Answer is B
Explanation
The correct answer is choice B. Check if there is any cross-sensitivity between erythromycin and penicillin.Erythromycin is a macrolide antibiotic that can be used to treat bacterial eye infections in newborns and adults.
Penicillin is a beta-lactam antibiotic that can cause allergic reactions in some people.
Cross-sensitivity means that a person who is allergic to one type of antibiotic may also be allergic to another type of antibiotic that has a similar structure or mechanism of action.Erythromycin and penicillin have different structures and mechanisms of action, but there is still a small chance of cross-sensitivity between them.
Therefore, the nurse should check if the newborn has any history of allergic reaction to penicillin before applying the erythromycin eye ointment.
Choice A is wrong because asking the mother if she has any allergies to antibiotics is not enough to determine if the newborn is at risk of an allergic reaction to erythromycin.
The newborn may have inherited or developed an allergy to penicillin or erythromycin that the mother does not have.
Choice C is wrong because applying a small amount of ointment on the skin to test for allergic reaction is not a reliable method to diagnose an allergy.Skin testing can cause false positive or false negative results, and it may also trigger a severe allergic reaction in some cases.
Choice D is wrong because administering an antihistamine to prevent anaphylaxis is not appropriate for a newborn who has not been exposed to the allergen yet.
An antihistamine is a medication that blocks the effects of histamine, a chemical that causes allergic symptoms.
Anaphylaxis is a life-threatening allergic reaction that involves multiple organ systems and requires immediate medical attention.An antihistamine cannot prevent anaphylaxis, and it may also cause side effects such as drowsiness, dry mouth, or low blood pressure in a newborn.
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
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.