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During the newborn admission assessment, the nurse palpates the newborn's scrotum and does not feel the testicles. Which assessment technique should the nurse perform next to verify the absence of testes?
- A. Observe the urethral opening on the surface of the penis when the newborn voids.
- B. Perform transillumination of the scrotal sac to visualize shadows of the testes.
- C. Use a fingertip to palpate the inguinal canal for a retractile or undescended testis.
- D. Measure the size of the scrotal sac for length and width.
Correct Answer: C
Rationale: If the testes are not palpated in the scrotum, the next step is to check the inguinal canal for a retractile or undescended testis. This technique allows the nurse to determine if the testes are located within the inguinal canal rather than the scrotum. It is essential to assess for the presence of testes in the inguinal canal to ensure proper diagnosis and management of any potential issues related to testicular positioning.
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During an examination for possible cryptorchidism in an infant, what technique should be used?
- A. Place the infant in a warm room and use a calm approach.
- B. Hold the scrotum and palpate gently.
- C. Cleanse the penis with an antiseptic-soaked pad.
- D. Position the infant in a warm room to prevent muscle contraction.
Correct Answer: D
Rationale: When examining an infant for cryptorchidism, it is important to position the infant in a warm room to prevent muscle contraction, which could cause the testes to retract. Placing the infant in a side-lying position may not be necessary for this specific examination. Holding the penis or retracting the foreskin is not relevant to the assessment for cryptorchidism. Cleansing the penis with an antiseptic pad is not indicated for this examination.
A woman at 36-weeks' gestation who is Rh negative is admitted to labor and delivery reporting abdominal cramping. She is placed on strict bedrest, and the fetal heart rate and contraction pattern are monitored with an external fetal monitor. The nurse notes a large amount of bright red vaginal bleeding. Which nursing intervention has the highest priority?
- A. Perform a sterile vaginal examination to determine dilatation.
- B. Determine fetal position by performing Leopold maneuvers.
- C. Assess the fetal heart rate and client's contraction pattern.
- D. Confirm Rh and Coombs status for Rho(D) immunoglobulin administration.
Correct Answer: C
Rationale: The highest priority nursing intervention in this scenario is to assess the fetal heart rate and the client's contraction pattern. The presence of a large amount of bright red vaginal bleeding in a woman at 36-weeks' gestation who is Rh negative raises concerns about the well-being of the fetus. Monitoring the fetal heart rate and contraction pattern will provide crucial information about fetal status and help determine the appropriate course of action to ensure the safety and health of both the mother and the baby.
An expectant father tells the LPN/LVN he fears that his wife 'is losing her mind.' He states she is constantly rubbing her abdomen and talking to the baby, and that she actually reprimands the baby when it moves too much. What recommendation should the nurse make to this expectant father?
- A. Reassure him that these are normal reactions to pregnancy and suggest that he discuss his concerns with the childbirth education nurse.
- B. Help him understand that his wife is experiencing normal maternal behaviors and bonding with the baby, and reassure him that these actions are positive.
- C. Ask him to observe his wife's behavior carefully for the next few weeks and report any similar behavior to the nurse at the next prenatal visit.
- D. Let him know that these behaviors are part of normal maternal-fetal bonding which occur once the mother feels fetal movement.
Correct Answer: D
Rationale: The father's concerns about his wife's behaviors can be addressed by explaining that behaviors like talking to the baby and responding to fetal movements are part of normal maternal-fetal bonding. These actions indicate that the mother is connecting with the baby and are positive signs of a healthy pregnancy. The nurse should reassure the father that these behaviors are common and beneficial for the mother-baby relationship during pregnancy.
The LPN/LVN is counseling a woman who wants to become pregnant. The woman tells the nurse that she has a 36-day menstrual cycle and the first day of her last menstrual period was January 8. The nurse calculates that the woman's next fertile period is
- A. January 14-15.
- B. January 22-23.
- C. January 30-31.
- D. February 6-7.
Correct Answer: C
Rationale: To determine the fertile period, subtract 14 days from the length of the woman's menstrual cycle. In this case, 36-14 = 22. Counting forward from the first day of the last menstrual period (January 8), the fertile period falls around January 30-31. This is because ovulation typically occurs approximately 14 days before the start of the next menstrual period, marking the fertile window for conception.
A full-term, 24-hour-old infant in the nursery regurgitates and suddenly turns cyanotic. What should the nurse do first?
- A. Suction the oral and nasal passages.
- B. Give oxygen by positive pressure.
- C. Stimulate the infant to cry.
- D. Turn the infant onto the right side.
Correct Answer: A
Rationale: In a situation where an infant regurgitates and turns cyanotic, the priority action should be to clear any potential airway obstruction. Suctioning the oral and nasal passages is crucial to ensure the infant's airway is clear and allow for proper breathing. This intervention takes precedence over providing oxygen, stimulating the infant to cry, or repositioning the infant.