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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?

A.

Wound infection.

B.

Ulceration.

C.

Exposure to urine.

D.

Healing.

Answer and Explanation

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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View Related questions

Correct Answer is A

Explanation

Choice A rationale

Music can be a non-pharmacological method to help manage pain and anxiety during the latent phase of labor.

Choice B rationale

Biofeedback might be helpful but can be challenging to implement without prior training.

Choice C rationale

Administering fentanyl 100 mg every hour is not appropriate; fentanyl is typically administered in much smaller doses.

Choice D rationale

A pudendal nerve block is usually reserved for the second stage of labor or delivery, not the latent phase.

Correct Answer is A

Explanation

  1. Preterm Labor Risk: At 32 weeks of gestation, regular contractions every 5 minutes could indicate the onset of preterm labor. This is concerning because preterm labor can lead to preterm birth, which poses significant risks to the baby's health and development.

  2. Frequency and Intensity: These contractions are occurring frequently (every 5 minutes) and are described as stronger than usual Braxton Hicks contractions. This frequency and the strength of the contractions are unusual for Braxton Hicks, which are typically irregular and less intense.

  3. Effacement and Cervical Changes: Although the cervix is closed, it is 80% effaced. Effacement means the cervix is thinning, which, in combination with regular contractions, may indicate that the body is preparing for labor.

  4. Urinary Leakage: The client also reported urinary leakage earlier in the day, which could be a sign of ruptured membranes (water breaking). This, combined with regular contractions, increases the need for careful monitoring.

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