The nurse finds that an infant admitted for surgical repair of an inguinal hernia voids a urinary stream from the ventral surface of the penis.
What action should the nurse take?
Assess for bladder distention.
Listen for bowel sounds.
Document the observation.
Check the scrotum for testicular descent.
The Correct Answer is C
Choice A rationale
While assessing for bladder distention is important in general urinary assessment, it is not directly related to the observation of the infant voiding a urinary stream from the ventral surface of the penis.
Choice B rationale
Listening for bowel sounds is a part of the general abdominal assessment. However, it does not provide information related to the observation of the infant voiding a urinary stream from the ventral surface of the penis.
Choice C rationale
Documenting the observation is the correct action. The nurse has observed that the infant voids a urinary stream from the ventral surface of the penis. This could indicate a condition such as hypospadias, where the urethral opening is on the underside of the penis. This is an important finding that should be documented and reported.
Choice D rationale
Checking the scrotum for testicular descent is part of the general assessment of the male genitalia. However, it does not provide information related to the observation of the infant voiding a urinary stream from the ventral surface of the penis.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A rationale
While using gestures with 1 to 2 word sentences is a developmental milestone, it is typically seen in younger children, around the age of 212.
Choice B rationale
Using 1 word sentences is a developmental milestone usually achieved by children around the age of 112. By the age of 3, children are typically able to speak in simple sentences with four or more words.
Choice C rationale
Speaking in simple sentences with four or more words is a typical developmental milestone for a 3-year-old child. They are able to express their thoughts more clearly and engage in conversations.
Choice D rationale
Recognizing most letters and numbers is a skill that is typically developed around the age of 4 or 512. Therefore, expecting a 3-year-old child to recognize most letters and numbers might be too advanced for their developmental stage.
Correct Answer is A
Explanation
Choice A rationale
Disseminated intravascular coagulation (DIC) is a serious complication that can occur after severe postpartum hemorrhage. It involves an abnormal activation of the clotting cascade, leading to the formation of small blood clots in the vessels and can result in organ damage.
Choice B rationale
Postpartum psychosis is a rare psychiatric emergency that typically presents with delirium and mood disturbances, and it is not directly related to postpartum hemorrhage.
Choice C rationale
While hard, painful uterine afterpains can occur after childbirth, they are not the highest priority for assessment in a client who experienced a severe postpartum hemorrhage.
Choice D rationale
Placenta accreta is a condition where the placenta attaches too deeply into the uterine wall. However, it is typically identified during pregnancy or at the time of delivery, not after a postpartum hemorrhage.
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