Nokea
The nurse notes swelling in the scrotum of a newborn infant. Transillumination reveals a reddish-yellow reflection. What action by the nurse is best?
- A. Document the findings and reassure the parents.
- B. Elevate the scrotum and apply ice for 20 minutes.
- C. Notify the health-care provider immediately.
- D. Obtain informed consent for emergent surgery.
Correct Answer: A
Rationale: When the nurse assesses a swollen scrotum, it is important to determine that the scrotal sac does not contain entrapped bowel or a mass. Transillumination can determine the presence of a mass when the light directed at the scrotum does not produce a reflection. A reddish-yellow reflection indicates fluid, which will be reabsorbed on its own. The nurse should document the findings and reassure the parents. No further action is needed.
You may also like to solve these questions
An infant at term was born at 0105 hours. The nurse is developing a plan of care for the newborn. During which time range will the nurse plan on performing the assessment to determine a Ballard score?
- A. 0115 to 0130
- B. 0200 to 0600
- C. 1400 to 1800
- D. 2000 to 2300
Correct Answer: B
Rationale: The correct answer is B (0200 to 0600) because the Ballard score is typically assessed within the first 12-24 hours of life. Given that the infant was born at 0105 hours, the nurse should plan on performing the assessment between 0200 to 0600. This time frame falls within the recommended window for assessing the Ballard score accurately. Choices A, C, and D are incorrect because they fall outside the optimal time range for conducting the assessment. Option A (0115 to 0130) is too soon after birth, and options C (1400 to 1800) and D (2000 to 2300) are too late for the initial assessment as per standard practice.
A student nurse is verbalizing disappointment in a new mothers seeming lack of interest in her newborn baby. The student complains to the registered nurse that the mother just wants to sleep and have someone else care for the infant. What response by the registered nurse is best?
- A. Assess closely; we may need to call social work.
- B. Dont judge other people until you have had a baby.
- C. The mother may be completely exhausted from the childbirth experience.
- D. We have to accept that everyones experience is different.
Correct Answer: C
Rationale: After a long and possibly difficult birth
The nurse is assigned to the postpartum room of a 12-hour-old neonate, and the EHR has a task reminder prompting the nurse to complete a Brazelton assessment on the newborn. Why is this not appropriate?
- A. This newborn has been born to a person who is placing the infant up for adoption.
- B. This newborn has been born to a person who birthed by cesarean section.
- C. This newborn is only 12 hours old.
- D. This newborn is experiencing pathologic jaundice.
Correct Answer: C
Rationale: The correct answer is C because performing a Brazelton assessment on a newborn who is only 12 hours old is not appropriate. The Brazelton assessment is typically done within the first 24-36 hours of life. Performing it too early may yield inaccurate results as the newborn is still transitioning and adapting to life outside the womb.
Choice A is not relevant to the appropriateness of the assessment timing. Choice B also does not impact the timing of the assessment. Choice D is also irrelevant to the timing of the assessment and would not affect the decision to delay performing the Brazelton assessment.
The nurse knows that during the interactive process of the Brazelton assessment, the newborn will receive an exceptionally good rating by reacting to what? Select all that apply.
- A. turns their head toward a familiar voice
- B. stays awake
- C. focuses on an object
- D. cries inconsolably
Correct Answer: C
Rationale: Reacting to a familiar voice, staying awake, and focusing on objects indicate strong interactive skills.
Which diagnosis is most appropriate for a newborn who has not voided within 24 hours after delivery?
- A. Hypovolemia related to insufficient fluid intake
- B. Altered growth and development related to gestational age of 36 weeks
- C. Altered nutrition, less than body requirements related to failure to properly latch onto the breast
- D. Constipation related to failure to pass a meconium stool and possible bowel obstruction
Correct Answer: A
Rationale: The correct answer is A: Hypovolemia related to insufficient fluid intake. In a newborn, the inability to void within 24 hours after birth can indicate dehydration and hypovolemia due to insufficient fluid intake. Newborns need to pass urine within the first 24 hours of life to show adequate hydration. Altered growth and development (choice B) is not relevant to the immediate concern of no voiding. Altered nutrition (choice C) is unlikely to cause the absence of urine output. Constipation (choice D) is less likely in a newborn and is not the primary concern when a newborn fails to void.