A nurse is caring for a newborn who had a circumcision 4 hr ago.During a diaper change, the nurse notes bright red blood oozing from the incision.
Which of the following actions should the nurse take?
Secure a clean diaper snugly across the newborn's penis.
Apply gentle pressure using a sterile dry gauze pad.
Rinse the newborn's penis with cool water.
Place petroleum jelly on the bleeding site.
The Correct Answer is B
Choice A rationale
Securing a clean diaper snugly across the newborn's penis might help manage minor bleeding but won't effectively address active oozing of bright red blood from a circumcision site.
Choice B rationale
Applying gentle pressure using a sterile dry gauze pad is the appropriate action to control bleeding. Applying direct pressure helps to stop the bleeding and allows for proper assessment of the wound.
Choice C rationale
Rinsing the newborn's penis with cool water might provide temporary relief but is not an effective method to control bleeding from a surgical site. It may also increase the risk of infection if not done sterilely.
Choice D rationale
Placing petroleum jelly on the bleeding site is typically done to prevent the diaper from sticking to the incision, but it is not sufficient to control active bleeding. .
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is []
Explanation
Based on the information provided, the client is most likely experiencing C. Hyperemesis gravidarum. This condition is characterized by severe nausea and vomiting, which can lead to dehydration and electrolyte imbalances.
Actions to Take:
- B. Inspect mucous membranes - To assess for signs of dehydration, such as dry mucous membranes.
- D. Administer antiemetic medications - To help control nausea and vomiting.
Parameters to Monitor:
- A. Electrolyte values - To monitor for any imbalances, especially given the low potassium level.
- B. Urine ketones - To check for ketonuria, which can indicate severe vomiting and dehydration.
Correct Answer is A
Explanation
Choice A rationale
"Decreased BP.”. This is correct because hyperemesis gravidarum can lead to dehydration, which in turn can cause hypotension (decreased blood pressure).
Choice B rationale
"WBC count 15,000/mm³ (5,000 to 15,000/mm³).”. This is incorrect because while WBC count can be elevated due to stress or infection, it is not a primary manifestation of hyperemesis gravidarum.
Choice C rationale
"Pruritus.”. This is incorrect because pruritus is not commonly associated with hyperemesis gravidarum. It is more likely related to other conditions like cholestasis of pregnancy.
Choice D rationale
"Hemoglobin 18 g/dL (11 to 16 g/dL).”. This is incorrect because an elevated hemoglobin level is not a direct manifestation of hyperemesis gravidarum, although dehydration can potentially concentrate blood components and slightly elevate hemoglobin.
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