A charge nurse is preparing to discuss actions to take for clients who require an amniotomy during labor with a newly licensed nurse.
Which of the following statements should the charge nurse include during the discussion?

Check the client's temperature frequently following the procedure.

Insert misoprostol rectally every 2 hours following the procedure.

Obtain a biophysical profile during the procedure.

Perform effleurage to the client's abdomen during the procedure.

Answer and Explanation

The Correct Answer is A

Choice A rationale

Checking the client's temperature frequently following the procedure is crucial. An amniotomy increases the risk of infection, so frequent monitoring of temperature helps in early detection and management of any potential infections.

Choice B rationale

Inserting misoprostol rectally every 2 hours following the procedure is not recommended. Misoprostol is a medication used for inducing labor or controlling postpartum hemorrhage, not for routine use post-amniotomy.

Choice C rationale

Obtaining a biophysical profile during the procedure is not relevant. A biophysical profile is an assessment of fetal well-being and is not typically performed during amniotomy.

Choice D rationale

Performing effleurage to the client's abdomen during the procedure is not necessary. Effleurage is a massage technique used for pain relief during labor, but it is not related to the management of an amniotomy. .

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Correct Answer is C

Explanation

Choice A rationale

Giving glucose water after feedings is not recommended for newborns undergoing phototherapy. Breastfeeding or formula feeding should be continued to provide adequate nutrition and hydration.

Choice B rationale

Instructing the client to avoid breastfeeding during treatment is not necessary. Breastfeeding should continue to promote bonding, provide nutrition, and help with the infant's hydration and bilirubin excretion.

Choice C rationale

Monitoring intake and output is crucial for a newborn receiving phototherapy to ensure proper hydration and assess the effectiveness of the treatment in lowering bilirubin levels.

Choice D rationale

Applying lotions and ointments throughout the treatment is not recommended, as they can interfere with the effectiveness of phototherapy. The skin should be clean and dry to maximize exposure to the phototherapy light.

A. Wound infection. B. Ulceration. C. Exposure to urine. D. Healing.

Correct Answer is D

Explanation

Choice A rationale

Wound infection usually presents with redness, warmth, and swelling, not just yellow exudate. The presence of yellow exudate alone typically does not indicate an infection.

Choice B rationale

Ulceration would involve the breakdown of skin or tissue, which is not indicated by the presence of yellow exudate. Ulcerations are more severe and painful than normal post-circumcision healing.

Choice C rationale

Exposure to urine can cause irritation but does not typically result in yellow exudate. Proper diapering and cleaning prevent this irritation, and exudate is part of the healing process, not a result of urine exposure.

Choice D rationale

Healing is indicated by the presence of yellow exudate, which is a normal part of the healing process post-circumcision. It signifies that the glans is recovering as expected. .

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A charge nurse is preparing to discuss actions to take for clients who require an amniotomy during labor with a newly licensed nurse.Which of the following statements should the charge nurse include during the discussion?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a 2-day-old newborn who has a bilirubin level of 14 mg/dL (1 to 12 mg/dL) and is to begin phototherapy.Which of the following actions should the nurse take?

Correct Answer is C

Explanation

A nurse is assessing a newborn following a circumcision 48 hours ago.The nurse should identify that yellow exudate covering the newborn's glans penis indicates which of the following?

Correct Answer is D

Explanation

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A charge nurse is preparing to discuss actions to take for clients who require an amniotomy during labor with a newly licensed nurse.Which of the following statements should the charge nurse include during the discussion?

A charge nurse is preparing to discuss actions to take for clients who require an amniotomy during labor with a newly licensed nurse.
Which of the following statements should the charge nurse include during the discussion?