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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. Right occiput posterior position: This position refers to the baby's head being down but facing the mother's back, which can make labor more challenging but is not a contraindication for amniotomy.
B. -2 station: This indicates that the baby's head is not yet engaged in the pelvis. While it can complicate labor, it is not an absolute contraindication for amniotomy, though caution is advised.
C. Cephalic presentation: This is the most common and favorable position for delivery, where the baby's head is down and ready for birth. It is not a contraindication for amniotomy.
D. Dilation less than 3 cm: This is a contraindication for amniotomy because the cervix is not sufficiently dilated, which can increase the risk of complications such as infection or prolonged labor.
Correct Answer is A
Explanation
Choice A reason:
This is the best response because it shows that the nurse is providing nonpharmacological pain relief measures and supporting the client's coping mechanisms. Breathing and imagery techniques can help the client relax and focus on something other than the pain. Moaning, screaming, and vocalizing are normal and acceptable ways of expressing pain during labor, and the nurse should not try to suppress them.
Choice B reason:
This is not the best response because it does not address the husband's concern or offer any intervention for the client's pain. Asking the client to rate her pain on a scale of 0 to 10 is a subjective assessment tool that may not reflect the true intensity of her pain. Furthermore, it may be difficult for the client to answer this question while she is in the second stage of labor.
Choice C reason:
This is not the best response because it may not be feasible or appropriate to administer more pain medication to the client in the second stage of labor. The obstetrician may not be available to evaluate the client's pain, and increasing the dose of pain medication may have adverse effects on the client and the fetus, such as respiratory depression, hypotension, and decreased uterine contractility.
Choice D reason:
This is not the best response because it does not acknowledge the husband's feelings or provide any comfort or education for him. Reassuring him that his wife will be fine may sound dismissive and insensitive, and offering to stay with her while he takes a walk may imply that he is not needed or wanted in the birthing room. The nurse should involve the husband in the care of his wife and explain to him what is happening and what to expect during labor.
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