A nurse is assessing a newborn following a circumcision 48 hr 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.
The Correct Answer is D
Choice A rationale
Wound infection following circumcision typically presents with signs such as erythema (redness), localized warmth, purulent drainage, and swelling, often accompanied by fever. Yellow exudate alone, without these other inflammatory indicators, does not align with the typical presentation of a bacterial infection.
Choice B rationale
Ulceration would manifest as an open sore or a break in the skin integrity, often with raw, exposed tissue. The yellow exudate covering the glans, if it represents a healing process, is a protective layer and not indicative of tissue breakdown or an open ulcer.
Choice C rationale
Exposure to urine does not typically result in a uniform yellow exudate covering the glans. While prolonged urine exposure can lead to skin irritation or maceration, the described finding is a distinct physiological response associated with tissue repair rather than simple urinary contact.
Choice D rationale
The formation of a yellow exudate or "scab" on the glans penis is a normal physiological response during the healing process after circumcision. This fibrinogen-rich layer acts as a protective barrier, preventing infection and facilitating re-epithelialization of the wound, and it typically resolves within 7-10 days.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["B","C"]
Explanation
Choice A rationale
Meconium stools are a normal physiological finding in a newborn during the first 24-48 hours of life. This thick, tarry, dark-green stool is composed of intestinal epithelial cells, amniotic fluid, bile, and water, reflecting fetal gastrointestinal tract development and function. Its presence indicates typical bowel activity.
Choice B rationale
Depressed fontanels indicate dehydration in a newborn. The fontanels are soft spots on a baby's head where the skull bones have not yet fused. When a baby is dehydrated, the fluid volume in the brain decreases, causing the fontanel to appear sunken below the normal contour of the skull, which necessitates immediate medical attention due to potential complications.
Choice C rationale
Rust-stained urine, also known as "brick dust" urine, in a newborn can indicate dehydration. This discoloration is caused by the excretion of urate crystals, which are a normal metabolic byproduct. However, in concentrated urine, these crystals become more visible, suggesting insufficient fluid intake and requiring further assessment to prevent significant dehydration.
Choice D rationale
Overlapping suture lines, also known as molding, are a common and expected finding in newborns, especially after vaginal delivery. This temporary reshaping of the fetal skull allows it to pass more easily through the birth canal and typically resolves spontaneously within a few days as the brain grows and fills the cranial cavity.
Correct Answer is {"A":{"answers":"A"},"B":{"answers":"A"},"C":{"answers":"A,B"},"D":{"answers":"A"}}
Explanation
- Uterine contractions: hallmark of preterm labor but not typical of PPROM alone unless labor ensues.
- Low backache: common symptom of preterm labor due to uterine activity and pelvic changes; not directly associated with PPROM unless labor begins.
- Vaginal discharge: can be increased in both preterm labor (e.g., mucus plug changes, bloody show) and PPROM (amniotic fluid leakage or altered discharge).
- Cervical effacement: characteristic of labor process (preterm labor), not typically present in PPROM unless labor starts.
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