A nurse is assessing a newborn following a circumcision 48 hours ago.
The nurse should identify that yellow exudate covering the newborn's glans penis indicates which of the following?
Wound infection.
Ulceration.
Exposure to urine.
Healing.
The Correct Answer is D
Choice A rationale
Wound infection usually presents with redness, warmth, and swelling, not just yellow exudate. The presence of yellow exudate alone typically does not indicate an infection.
Choice B rationale
Ulceration would involve the breakdown of skin or tissue, which is not indicated by the presence of yellow exudate. Ulcerations are more severe and painful than normal post-
circumcision healing.
Choice C rationale
Exposure to urine can cause irritation but does not typically result in yellow exudate. Proper diapering and cleaning prevent this irritation, and exudate is part of the healing process,
not a result of urine exposure.
Choice D rationale
Healing is indicated by the presence of yellow exudate, which is a normal part of the healing process post-circumcision. It signifies that the glans is recovering as expected. .
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Correct Answer is ["A","B"]
Explanation
Choice A rationale
Blood pressure should be assessed as opioid analgesics can cause hypotension, which can be detrimental to both mother and fetus during labor.
Choice B rationale
Fetal heart rate monitoring is essential as opioids can cross the placenta and potentially cause fetal bradycardia or distress, thus necessitating close monitoring.
Choice C rationale
Deep tendon reflexes are not commonly affected by opioid analgesics and therefore are not a primary assessment when administering these medications during labor.
Choice D rationale
Blood glucose levels are not typically influenced by opioid analgesics in the context of labor, so this is not a relevant assessment for this scenario.
Correct Answer is C
Explanation
Choice A rationale
Cooling the newborn’s heel would constrict blood vessels and make it more difficult to obtain a blood sample. Warming the heel is the preferred method to increase blood flow.
Choice B rationale
Puncturing the center of the newborn’s heel is not recommended as it could cause more pain and potential injury to the bone. The puncture should be done on the outer edges of the heel.
Choice C rationale
Cleansing the puncture site with alcohol gauze is essential to reduce the risk of infection and ensure that the sample is not contaminated.
Choice D rationale
Administering vitamin K before each blood draw is unnecessary. Vitamin K is typically given as a one-time dose to prevent bleeding issues, not related to blood draw procedures.