Nokea
The nurse is caring for the full-term newborn male who is 24 hours old and was circumcised with a Gomco clamp 30 minutes ago. Which interventions should the nurse plan for care of the newborn’s circumcision? Select all that apply.
- A. Monitor the newborn’s penis hourly for 4 to 6 hours.
- B. Observe for and document the first voiding after circumcision.
- C. Use prepackaged commercial diaper wipes for perineal cleansing.
- D. Apply petroleum ointment around the penis after each diaper change.
- E. Apply tightly a size-smaller diaper to provide hemostasis.
Correct Answer: A,B,D
Rationale: Monitor the penis for swelling/bleeding document first void to rule out obstruction and apply petroleum ointment to prevent bleeding. Commercial wipes may irritate and tight diapers cause pain.
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Which client symptoms documented by the nurse best indicate that the child is having a hypoglycemic reaction? Select all that apply.
- A. The child complains of being thirsty.
- B. The child's breathing is labored and prolonged.
- C. The child is more hungry than usual.
- D. The child complains of feeling shaky.
- E. The child reports feeling light-headed.
- F. The child states his or her heart is racing.
Correct Answer: D,E,F
Rationale: Hypoglycemia causes shakiness, light-headedness, and tachycardia due to low blood glucose triggering the sympathetic nervous system. Thirst and hunger are less specific, and labored breathing is unrelated.
Which assessment finding may indicate a serious neurovascular problem that should be reported immediately to the charge nurse or physician?
- A. The toes of the left foot are warmer than the toes of the right foot.
- B. The toes of both feet are cool to the touch.
- C. The child is unable to wiggle the toes of the right foot.
- D. The capillary refill in the toes of the right foot is 2 seconds.
Correct Answer: C
Rationale: Inability to wiggle toes suggests neurovascular compromise, such as nerve or vascular injury, requiring immediate reporting to prevent permanent damage.
When assessing the infant undergoing phototherapy for hyperbilirubinemia,the nurse notes a maculopapular rash over the infant’s buttocks and back. What action should the nurse take next?
- A. Document the results in the newborn’s medical record.
- B. Call the HCP immediately to report this finding.
- C. Discontinue the phototherapy immediately.
- D. Assess the infant’s axillary temperature.
Correct Answer: A
Rationale: A transient maculopapular rash is a common benign side effect of phototherapy requiring only documentation. No further action is needed.
The nurse advises the parents that the child is due to receive which of the following immunization boosters?
- A. Haemophilus influenzae type b (Hib)
- B. Polio
- C. Smallpox
- D. Tetanus
Correct Answer: D
Rationale: A 14-year-old is due for a tetanus-diphtheria-pertussis (Tdap) booster, typically recommended at 11-12 years if not received since age 6, to maintain immunity.
A healthy postpartum mother who is breastfeeding her term infant tells the nurse that she has noticed that her roommate is feeding iron-enriched formula to her newborn. The mother asks if she should be giving her baby supplemental iron. Which response by the nurse is correct?
- A. “Your breast milk provides all the iron your baby needs.”
- B. “You,not your baby will need an iron supplement daily.”
- C. “Your pediatrician will prescribe iron drops for your baby.”
- D. “You should feed your baby iron-fortified formula once daily.”
Correct Answer: A
Rationale: Breast milk provides sufficient highly bioavailable iron for term infants making supplementation unnecessary. Maternal iron supplements or formula feeding are not required.