The nurse is inspecting a male newborn's genitalia. Which action should the nurse avoid when conducting this assessment?
Inspecting if the urethral opening appears circular.
Retracting the foreskin over the glans to assess for secretions.
Palpating if testes are descended into the scrotal sac.
Inspecting the genital area for irritated skin.
The Correct Answer is B
Choice A reason:
Inspecting if the urethral opening appears circular. This is a correct action for the nurse to do, as it helps to identify any abnormalities in the urethral opening, such as hypospadias or epispadias, which are congenital defects where the opening is located on the underside or the top of the penis, respectively. • Choice B reason:
Retracting the foreskin over the glans to assess for secretions. This is an incorrect action for the nurse to avoid, as it can cause pain, bleeding, and infection in the newborn. The foreskin is usually adhered to the glans in newborns and should not be forcibly retracted. It will gradually loosen over time and can be retracted by the child himself when he is older. •
Choice C reason:
Palpating if testes are descended into the scrotal sac. This is a correct action for the nurse to do, as it helps to detect any undescended testes, which are more common in preterm infants and can increase the risk of infertility and testicular cancer later in life. • Choice D reason:
Inspecting the genital area for irritated skin. This is a correct action for the nurse to do, as it helps to identify any signs of diaper rash, fungal infection, or allergic reaction in the newborn's skin.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A reason:
Maternal exhaustion is a maternal indication for the use of vacuum extraction. Vacuum extraction is a technique that can assist the mother in delivering the baby when she is unable to push effectively or when pushing poses a risk to her health. Vacuum extraction can shorten the second stage of labor and reduce maternal fatigue and distress. According to the Cleveland Clinic, vacuum extraction might be indicated if "the mother can't push anymore, either due to exhaustion or a health condition.".
Choice B reason:
Failure to progress past 0 station is not a maternal indication for the use of vacuum extraction. The station refers to the position of the baby's head in relation to the mother's pelvis. 0 station means that the baby's head is at the level of the pelvic inlet, or the narrowest part of the pelvis. Vacuum extraction is usually not performed before the baby reaches +2 station, which means that the head is 2 cm below the pelvic inlet and visible at the vaginal opening. According to the American Academy of Family Physicians, vacuum extraction should not be attempted if "the fetal head is not engaged (above 0 station).".
Choice C reason:
A wide pelvic outlet is not a maternal indication for the use of vacuum extraction. The pelvic outlet is the lower part of the pelvis that forms the exit for the baby during delivery. A wide pelvic outlet means that there is more space for the baby to pass through, which can facilitate vaginal delivery and reduce the need for instrumental assistance. Vacuum extraction is more likely to be indicated when there is a narrow pelvic outlet, which can obstruct labor and cause fetal distress.
Choice D reason:
A history of rapid deliveries is not a maternal indication for the use of vacuum extraction. Rapid deliveries, also known as precipitous deliveries, are those that occur within 3 hours of the onset of labor. Rapid deliveries can pose risks to both the mother and the baby, such as excessive bleeding, umbilical cord prolapse, or birth trauma. However, vacuum extraction is not usually indicated in these cases, as it requires time and preparation to apply the device and monitor its effects. Vacuum extraction is more likely to be indicated when labor is prolonged or stalled in the second stage, and when there is a nonreassuring fetal heart rate.
Correct Answer is D
Explanation
Choice A reason:
Measuring urinary output. This is not the priority nursing care associated with an oxytocin infusion, because urinary output is not directly affected by oxytocin. Urinary output may be affected by other factors, such as fluid intake, dehydration, or kidney function, but these are not related to oxytocin administration. • Choice B reason:
Evaluating cervical dilation. This is also not the priority nursing care associated with an oxytocin infusion, because cervical dilation is a result of uterine contractions, not oxytocin itself. Oxytocin is used to stimulate or augment uterine contractions, but it does not cause cervical dilation directly. Cervical dilation is important to monitor during labor, but it is not the main focus of oxytocin infusion. • Choice C reason:
Increasing infusion rate every 30 minutes. This is not the priority nursing care associated with an oxytocin infusion, because increasing the infusion rate every 30 minutes is not a standard protocol for oxytocin administration. The infusion rate should be adjusted according to the patient's response and the provider's orders, but not arbitrarily or routinely. Increasing the infusion rate too quickly or too often can cause hyperstimulation of the uterus, which can be dangerous for both the mother and the fetus.
• Choice D reason:
Monitoring uterine response. This is the correct answer and the priority nursing care associated with an oxytocin infusion, because oxytocin can cause excessive or prolonged uterine contractions, which can lead to fetal distress, uterine rupture, or placental abruption. Therefore, the nurse must monitor the frequency, duration, and intensity of uterine contractions, as well as the fetal heart rate and blood pressure, to ensure that oxytocin is having the desired effect and not causing any adverse outcomes.
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