Which of the following actions should the nurse take for a newborn immediately following birth who has an omphalocele?

Apply petroleum gauze to the viscera.

Position the newborn in a supine position.

Place the newborn under a radiant heat source.

Use sterile plastic wrap to cover the viscera.

Answer and Explanation

The Correct Answer is D

Choice A reason: Applying petroleum gauze to an omphalocele is inappropriate, as it does not provide a sterile barrier and risks infection or adhesion to exposed viscera. Omphaloceles require protection from contamination and dehydration, which sterile plastic wrap achieves, preserving bowel integrity until surgical repair, per neonatal surgical protocols.

Choice B reason: Positioning a newborn with an omphalocele in a supine position risks pressure on exposed viscera, potentially causing trauma or ischemia. A side-lying position supports the defect, preventing bowel damage. Proper positioning minimizes complications before surgical correction, as supine posture does not protect the omphalocele’s delicate membrane.

Choice C reason: Placing the newborn under a radiant heat source without covering the omphalocele risks dehydration and injury to exposed viscera. While thermoregulation is important, uncovered viscera lose moisture and are prone to infection. Sterile wrapping takes priority to protect the defect, followed by controlled warming, per neonatal care standards.

Choice D reason: Using sterile plastic wrap to cover the omphalocele prevents infection and dehydration of exposed viscera, maintaining bowel integrity until surgical repair. The wrap creates a sterile barrier, reducing bacterial contamination and fluid loss, critical for stabilizing the newborn’s condition and supporting preoperative management, per congenital defect care protocols.

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Correct Answer is D

Explanation

Choice A reason: Palpation of the fetal presenting part in the cervical os indicates labor progression or malpresentation, not uterine rupture. Uterine rupture involves uterine wall tearing, causing hemorrhage or fetal extrusion, not cervical findings. This finding is unrelated to the catastrophic internal bleeding or placental disruption characteristic of rupture.

Choice B reason: Severe bradypnea (respiratory rate of 10/min) is not a primary sign of uterine rupture. Rupture causes hemorrhage, leading to hypovolemic shock with symptoms like hypotension or tachycardia. Respiratory changes may occur secondary to shock but are not specific. Uterine rupture primarily affects cardiovascular stability, not respiratory rate.

Choice C reason: A sudden gush of amniotic fluid indicates membrane rupture, a normal labor event, not uterine rupture. Uterine rupture involves uterine wall tearing, causing bleeding or fetal distress, not fluid release. Amniotic fluid loss is unrelated to the structural failure or hemorrhagic shock associated with uterine rupture in VBAC.

Choice D reason: Hypotension (85/40 mm Hg) indicates uterine rupture, as it suggests hypovolemic shock from internal hemorrhage due to uterine wall tearing. Blood loss reduces intravascular volume, impairing cardiac output and placental perfusion. This life-threatening sign in VBAC requires immediate intervention to address maternal and fetal compromise, aligning with rupture’s pathophysiology.

A. Wash the circumcision site with mild soap and water 24 hr following the procedure. B. Take off the plastic bell 2 hr after the procedure. C. Monitor for bleeding every 15 min for the first hour. D. Remove the yellow drainage on the second postoperative day.

Correct Answer is C

Explanation

Choice A reason: Washing the circumcision site with soap and water 24 hours post-procedure risks disrupting the healing process. The plastic bell device remains in place for 5-7 days, and cleaning should avoid soap to prevent irritation. Healing relies on a dry environment to promote tissue repair and prevent infection.

Choice B reason: Removing the plastic bell 2 hours after circumcision is incorrect, as it is designed to remain in place for 5-7 days until the foreskin necroses and detaches. Premature removal risks bleeding and incomplete circumcision. The device ensures controlled tissue compression, supporting hemostasis and proper healing through localized necrosis.

Choice C reason: Monitoring for bleeding every 15 minutes for the first hour is critical, as circumcision carries a risk of hemorrhage due to penile vascularity. Frequent checks ensure early detection of complications, as neonatal coagulation is immature. This intervention supports hemostasis monitoring, aligning with post-surgical care to prevent significant blood loss.

Choice D reason: Removing yellow drainage on day two is inappropriate, as it may represent normal fibrinous exudate, a part of healing. Disturbing it risks infection or delayed tissue repair. The plastic bell promotes necrosis and healing, and exudate is expected unless accompanied by pus or odor, indicating infection.

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Which of the following actions should the nurse take for a newborn immediately following birth who has an omphalocele?

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