The parents of a male infant newborn have signed an informed consent for circumcision. Which priority intervention should the nurse implement upon completion of the circumcision procedure?

Give a PRN prescribed dose of liquid acetaminophen.

Wrap the infant in a warm receiving blankets.

Offer a pacifier dipped in glucose water.

Place petrolatum applied gauze dressings on the circumcision site.

Answer and Explanation

The Correct Answer is D

Choice A reason: Acetaminophen reduces pain but is secondary to preventing infection and bleeding with petrolatum dressings. Dressings are the immediate post-circumcision priority to protect the surgical site, per circumcision care and infection control protocols in neonatal nursing practice.

Choice B reason: Wrapping in blankets maintains warmth but does not address the surgical site’s immediate needs. Petrolatum dressings prevent infection and adhesion, critical post-circumcision. Warmth is secondary, per circumcision care and neonatal thermoregulation standards in nursing practice.

Choice C reason: Offering a glucose-dipped pacifier soothes but does not protect the circumcision site from infection or bleeding. Petrolatum dressings are the priority to ensure healing and comfort, per circumcision care and postoperative pain management standards in neonatal nursing practice.

Choice D reason: Applying petrolatum gauze dressings prevents infection, promotes healing, and reduces adhesion of the circumcision site to diapers. This is the priority intervention to protect the surgical wound, per evidence-based circumcision care and infection control protocols in neonatal nursing practice.

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Correct Answer is C

Explanation

Choice A reason: Measuring abdominal girth monitors distention but is less critical before digital removal of a fecal impaction. Impaction causes constipation, but girth changes are slow. Vital signs detect autonomic responses like bradycardia from vagal stimulation during the procedure, making them more urgent to ensure safety.

Choice B reason: Bowel sounds indicate motility, reduced in impaction, but do not predict complications during digital removal, which risks vagal stimulation causing bradycardia. Vital signs are critical, detecting cardiovascular instability, ensuring safety during this invasive procedure, making bowel sounds less immediate for assessment.

Choice C reason: Assessing vital signs is essential, as digital removal stimulates rectal nerves, potentially triggering a vagal response, causing bradycardia or hypotension. This risks syncope or shock. Monitoring heart rate and blood pressure ensures cardiovascular stability, preventing complications during this procedure, addressing autonomic risks effectively.

Choice D reason: Breath sounds assess respiratory status, unrelated to fecal impaction removal, a gastrointestinal issue. The procedure risks vagal stimulation, not pulmonary effects. Vital signs detect cardiovascular changes like bradycardia, ensuring safety during rectal manipulation, making breath sounds irrelevant for this assessment.

A. Blood pressure is 142/88 mm Hg. B. 2+ edema of fingers and hands. C. Radial pulse volume is 3+. D. Capillary refill time is 2 seconds.

Correct Answer is B

Explanation

Choice A reason: Blood pressure of 142/88 mm Hg indicates mild hypertension but does not directly affect pulse oximetry, which measures arterial oxygen saturation via hemoglobin light absorption. Hypertension does not typically cause hypoxemia (91% SpO₂). Edema is more likely, as it disrupts sensor accuracy, leading to false low readings.

Choice B reason: 2+ edema in fingers and hands impairs pulse oximeter accuracy, as fluid in tissues scatters light, reducing the sensor’s ability to detect arterial hemoglobin saturation. This causes falsely low SpO₂ readings (91%), common in edema from heart failure, making it the primary contributor to the inaccurate measurement.

Choice C reason: A radial pulse volume of 3+ indicates strong arterial flow, supporting accurate pulse oximetry by ensuring perfusion. This does not explain a low SpO₂ of 91%, as strong pulses enhance sensor reliability. Edema’s interference with light transmission is more likely to cause the reduced reading.

Choice D reason: Capillary refill of 2 seconds is normal, indicating adequate perfusion. This does not contribute to a low SpO₂ (91%), as pulse oximetry measures arterial flow, not capillary dynamics. Edema disrupts light transmission, causing inaccurate readings, making it the most likely cause of the observed saturation.

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The parents of a male infant newborn have signed an informed consent for circumcision. Which priority intervention should the nurse implement upon completion of the circumcision procedure?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Prior to initiating digital removal of a fecal impaction, it is most important for the nurse to perform which client assessment?

Correct Answer is C

Explanation

The nurse attaches a pulse oximeter to a client’s finger and obtains an oxygen saturation reading of 91%. Which assessment finding most likely contributes to this reading?

Correct Answer is B

Explanation

Following a ureterolithotomy, the client has a ureteral catheter in place. Which intervention should the nurse implement?

On the second postoperative day, a client reports increasing abdominal pain. Assessment findings include a distended abdomen with absent bowel sounds. Which intervention should the nurse anticipate implementing?

A client who had a radical neck dissection returns to the surgical unit with two surgical drains in the right side of the incision. One drain bulb is open and has minimal drainage. Which action should the nurse take to increase drainage into the drain?

When conducting discharge teaching for a client diagnosed with diverticulosis, which diet instruction should the nurse include?

The nurse is initiating a 24-hour urine collection for a client with an indwelling urinary catheter. After emptying all the urine from the collection bag, which action is most important for the nurse to implement?

Based on the capillary glucose measurement, a client is to receive 10 units of regular insulin. The client’s medication drawer contains one vial of a 70/30 mixture of regular insulin and isophane insulin. How should the nurse prepare the prescribed dose?