The parents of a male newborn have signed an informed consent for circumcision. Which priority intervention should the nurse implement upon completion of the circumcision?
Offer a pacifier dipped in glucose water.
Give a PRN dose of liquid acetaminophen.
Place petrolatum gauze dressings on the site.
Wrap the infant in warm receiving blankets.
The Correct Answer is C
Choice A rationale
Glucose water may be soothing due to the sweet taste, but it does not address the immediate need to protect the circumcision site from infection and aid in healing.
Choice B rationale
Liquid acetaminophen provides pain relief, but it does not address the immediate need to protect the circumcision site. Pain management alone is not sufficient for postoperative care.
Choice C rationale
Applying petrolatum gauze dressings on the site prevents the wound from sticking to the diaper, reduces irritation, and protects against infection, promoting healing. This is a priority intervention post-circumcision.
Choice D rationale
While keeping the infant warm is important for comfort and stability, it does not directly address the need to care for the circumcision site to prevent complications and promote healing.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","B","C","D"]
Explanation
Choice A rationale
Evaluating fetal heart rate and contraction patterns is critical as magnesium sulfate can impact uterine activity and fetal well-being. Monitoring ensures timely intervention if abnormalities in fetal status or labor progression are detected.
Choice B rationale
Obtaining a prescription to repeat the hepatic panel is necessary to monitor liver function, especially if there is a suspicion of HELLP syndrome (Hemolysis, Elevated Liver enzymes, Low Platelet count) which complicates severe preeclampsia.
Choice C rationale
Monitoring for evidence of seizure activity is crucial as the patient is receiving magnesium sulfate for eclampsia prophylaxis. Close observation helps in early detection and management of any seizure episodes, preventing complications.
Choice D rationale
Checking urinary output in an hourly urinometer is essential to assess renal function, as preeclampsia and magnesium sulfate can affect renal perfusion and output. Monitoring ensures timely intervention if there is a decline in output.
Choice E rationale
Inspecting the perineum for vaginal bleeding is less immediately relevant unless there is a concern for placental abruption or other obstetric complications. Focus on maternal systemic symptoms and fetal monitoring is more critical initially.
Correct Answer is C
Explanation
Choice A rationale
Caput succedaneum is a benign, self-limiting condition and does not require direct pressure. It resolves on its own within a few days after birth. Applying pressure may cause unnecessary discomfort to the newborn.
Choice B rationale
A STAT CT scan of the head is not necessary for diagnosing cephalhematoma, which is a localized collection of blood between the skull and periosteum. CT scans are typically reserved for more severe neurological concerns.
Choice C rationale
A cephalhematoma, characterized by swelling that does not cross suture lines, requires notification of the pediatrician. It may increase the risk of hyperbilirubinemia and needs monitoring for potential complications.
Choice D rationale
While assessing neurological vital signs every 4 hours is important for overall newborn care, it does not address the specific condition of cephalhematoma. The primary concern is monitoring for complications such as jaundice.
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