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 A
Explanation
Choice A rationale
In the scenario of ruptured membranes with a breech presentation, there is an elevated risk of umbilical cord prolapse due to the disproportionate fit of the presenting part in the maternal pelvis. Checking fetal heart tones immediately allows for rapid detection of cord compression, which manifests as abrupt decelerations, indicating fetal distress and necessitating urgent intervention.
Choice B rationale
While a cesarean birth is often indicated for breech presentations, especially with ruptured membranes, it is not the immediate first action. The priority is to assess fetal well-being, specifically ruling out umbilical cord prolapse, as this is an acute emergency that requires immediate intervention to prevent fetal hypoxia and mortality, prior to surgical preparation.
Choice C rationale
Assessing the color, amount, and odor of the amniotic fluid provides information about potential infection or meconium presence, which are important data points. However, the immediate life-threatening complication with ruptured membranes and breech presentation is umbilical cord prolapse, making fetal heart tone assessment a more urgent priority.
Choice D rationale
Performing a Nitrazine test confirms the rupture of membranes, but the client has already reported "my water just broke.”. While a confirmatory test, it is not the immediate priority. The critical concern is the potential for umbilical cord prolapse, which directly impacts fetal oxygenation and requires immediate assessment via fetal heart tones.
Correct Answer is A
Explanation
Choice A rationale
For clients prescribed methadone during pregnancy, breastfeeding is generally encouraged due to the benefits of breast milk for the infant. Methadone excretion into breast milk is minimal and not considered harmful, and it can help to reduce the severity of neonatal abstinence syndrome.
Choice B rationale
Methamphetamine use during pregnancy is associated with several adverse fetal outcomes, but fetal macrosomia (abnormally large baby) is not typically one of them. Instead, it is more commonly linked to intrauterine growth restriction, preterm birth, and small for gestational age infants due to vasoconstrictive effects.
Choice C rationale
For newborns experiencing neonatal abstinence syndrome due to prenatal substance exposure, environmental stimuli should be decreased, not increased. Reducing stimuli like bright lights, loud noises, and excessive handling helps to minimize agitation, irritability, and seizures in these vulnerable infants.
Choice D rationale
Increased head circumference is not an expected finding in a newborn with fetal alcohol syndrome (FAS). In fact, microcephaly (abnormally small head circumference) is a characteristic diagnostic criterion for FAS, reflecting the detrimental effects of alcohol on fetal brain development.
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