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?

Wound infection.

Ulceration.

Exposure to urine.

Healing.

Answer and Explanation

The Correct Answer is D

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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Correct Answer is A

Explanation

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. .

A. Heart rate 132/min. B. Report of headache. C. Nasal congestion. D. Tremors.

Correct Answer is A

Explanation

Choice A rationale

Terbutaline can cause tachycardia. A heart rate of 132/min is significantly higher than normal and could indicate severe cardiovascular effects.

Choice B rationale

While headaches can occur with terbutaline, they are generally not life-threatening and don't require immediate intervention compared to tachycardia.

Choice C rationale

Nasal congestion is a minor side effect and not a priority compared to a significantly elevated heart rate.

Choice D rationale

Tremors are common with terbutaline use, but they are usually not as concerning as a significantly elevated heart rate.

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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?

Nursing Test Bank

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Explanation

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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?