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: Imbalanced nutrition is unrelated to 150 mL residual urine, which indicates incomplete bladder emptying, often from detrusor dysfunction or obstruction. Nutrition affects overall health but does not cause retention. Residual urine increases infection risk due to stasis, making nutrition an irrelevant nursing problem for this urinary issue.

Choice B reason: Deficient fluid volume suggests dehydration, reducing urine output, not causing high residual volumes. Residual urine (150 mL) indicates retention from impaired bladder emptying, not fluid deficit. Hydration prevents stasis, but infection risk from retained urine is more immediate, as bacteria proliferate in stagnant urine.

Choice C reason: Residual urine of 150 mL signifies incomplete bladder emptying, often from obstruction or neurogenic bladder, leading to urinary stasis. This fosters bacterial growth, increasing urinary tract infection (UTI) risk. Including “risk for infection” addresses this pathophysiological concern, guiding interventions like catheterization to reduce infection likelihood.

Choice D reason: Urinary incontinence involves involuntary leakage, not retention, where the bladder fails to empty, as seen with 150 mL residual urine. Retention results from outflow obstruction or weak detrusor, distinct from incontinence’s loss of control, making this nursing problem inappropriate for the client’s condition.

A. Question the client about related symptoms. B. Palpate the inguinal area for a bulge. C. Inspect the urethral meatus for abnormalities. D. Observe the scrotum for swelling.

Correct Answer is A

Explanation

Choice A reason: Questioning about related symptoms (e.g., urgency, frequency) clarifies nocturia and hesitancy, suggesting causes like benign prostatic hyperplasia. This comprehensive data guides targeted assessments, ensuring accurate diagnosis and treatment, per urological assessment and patient history standards in elderly male nursing care.

Choice B reason: Palpating for an inguinal bulge assesses hernia, unrelated to nocturia or hesitancy. Questioning related symptoms better identifies urinary issues, guiding diagnosis. Hernias are not primary causes, per urological assessment and differential diagnosis protocols in nursing care for urinary complaints.

Choice C reason: Inspecting the meatus for abnormalities or discharge may follow but is less comprehensive than symptom questioning, which broadens the urinary history. Symptoms like hesitancy suggest internal issues, per urological assessment and benign prostatic hyperplasia diagnostic standards in nursing practice for elderly men.

Choice D reason: Observing scrotal swelling assesses testicular issues, not directly linked to nocturia or hesitancy. Questioning symptoms like weak stream or dribbling prioritizes urinary tract evaluation, per urological and geriatric assessment protocols in nursing care for male urinary symptoms.

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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

After a client voids, 150 mL of residual urine is measured. Which nursing problem should be included in this client’s plan of care?

Correct Answer is C

Explanation

An older male client reports nocturia with difficulty starting his urine stream. Which additional assessment should the nurse perform to obtain further data related to this information?

Correct Answer is A

Explanation

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