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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:

A.

Apply gentle pressure to stop bleeding

B.

Change his diaper more frequently

C.

Document this as a normal finding

D.

Notify his physician

Answer and Explanation

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 C

Explanation

The correct answer is choice C. A temperature of 36°C (96.8°F) is below the normal range for a newborn, which is 36.5°C to 37.5°C (97.7°F to 99.5°F).

A low temperature can indicate hypothermia, infection, or hypoglycemia, and should be reported to the provider.

Choice A is wrong because a heart rate of 140/min is within the normal range for a newborn, which is 120 to 160/min.

Choice B is wrong because a respiratory rate of 50/min is within the normal range for a newborn, which is 30 to 60/min.

Choice D is wrong because a blood pressure of 60/40 mm Hg is within the normal range for a newborn, which is 50 to 75/30 to 45 mm Hg.

Correct Answer is A

Explanation

The correct answer is choice A.Factor II, also known as prothrombin, is one of the coagulation factors that are activated by vitamin K.Vitamin K is a cofactor for the carboxylation of specific glutamic acid groups in coagulation factors II, VII, IX, and X.

This process is essential for the activation of these factors in the coagulation cascade.

Choice B is wrong because factor V is not a vitamin K-dependent coagulation factor.

Factor V is activated by thrombin and acts as a cofactor for factor Xa in the conversion of prothrombin to thrombin.

Choice C is wrong because factor VIII is not a vitamin K-dependent coagulation factor.

Factor VIII is activated by thrombin and acts as a cofactor for factor IXa in the activation of factor X.

Choice D is wrong because factor XI is not a vitamin K-dependent coagulation factor.

Factor XI is activated by factor XIIa and activates factor IX in the intrinsic pathway of coagulation.

Normal ranges for coagulation factors are:

• Factor II: 70-120% of normal activity

• Factor V: 50-150% of normal activity

• Factor VIII: 50-150% of normal activity

• Factor IX: 50-150% of normal activity

• Factor X: 70-140% of normal activity

• Factor XI: 70-150% of normal activity

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