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.
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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. Give the vaccine intramuscularly in the anterolateral thigh.
This is because the anterolateral thigh is the recommended site for intramuscular injections in infants less than 12 months of age.
It has a large muscle mass and minimal risk of injury to nerves or blood vessels.
Choice A is wrong because informed consent is not required for routine immunizations, unless the parent or guardian requests more information or declines the vaccine.
Choice C is wrong because hepatitis B immune globulin (HBIG) is only indicated for newborns whose mothers are hepatitis B surface antigen positive (HBsAg+), as they have a high risk of acquiring the infection from their mothers.
Choice D is wrong because there is no need to delay giving the vaccine until after breastfeeding is established.
Breastfeeding does not interfere with the vaccine’s effectiveness or safety, and it does not increase the risk of adverse reactions.
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