A male newborn infant has just been circumcised. The nurse checks the surgical site, expecting it to have what appearance?

Choice A reason:

Antibiotic ointment to both eyes: This is typically administered to newborns to prevent bacterial infections such as gonorrhea and chlamydia, which can be contracted during birth. The ointment helps prevent neonatal conjunctivitis, a serious eye infection that can lead to blindness if untreated.

Choice B reason:

Hepatitis B immunization: Newborns are given the hepatitis B vaccine to protect them from the hepatitis B virus, which can cause serious liver disease. This vaccine is usually administered within the first 24 hours of birth.

Choice C reason:

Lidocaine gel to the umbilical stump: This is not a standard practice for newborn care. The umbilical stump is typically kept clean and dry to prevent infection, but lidocaine gel is not used for this purpose.

Choice D reason:

Haemophilus influenzae type b immunization: This vaccine is not typically given to newborns immediately after birth. It is usually administered starting at 2 months of age as part of the routine immunization schedule.

Choice E reason:

Vitamin K injection: Newborns have low levels of vitamin K, which is necessary for blood clotting. A vitamin K injection is given shortly after birth to prevent bleeding disorders.

Choice A reason:

Assessing maternal blood glucose is important in various clinical scenarios, such as managing diabetes during pregnancy. However, it is not directly related to the immediate issue of magnesium sulfate toxicity. Magnesium sulfate can cause respiratory depression, and a respiratory rate of 10/min is a critical sign that requires immediate intervention to prevent further complications.

Choice B reason:

Discontinuing the magnesium infusion is the priority intervention. Magnesium sulfate toxicity can lead to severe respiratory depression, hypotension, and loss of deep tendon reflexes. A respiratory rate of 10/min indicates significant respiratory depression, which can be life-threatening. Stopping the infusion immediately helps to prevent further accumulation of magnesium in the body and allows for the administration of the antidote, calcium gluconate, if necessary.

Choice C reason:

Preparing for an emergency cesarean birth is a critical intervention in cases of fetal distress or other obstetric emergencies. However, in this scenario, the immediate concern is the client’s respiratory depression due to magnesium sulfate toxicity. Addressing the respiratory issue takes precedence to stabilize the client before considering any surgical interventions.

Choice D reason:

Placing the client in Trendelenburg position is typically used to treat hypotension or shock by promoting venous return to the heart. While it can be beneficial in certain situations, it does not address the primary issue of respiratory depression caused by magnesium sulfate toxicity. The priority is to discontinue the magnesium infusion and manage the respiratory depression.