A nurse is caring for a newborn who had a circumcision 4 hr ago.
During a diaper change, the nurse notes bright red blood oozing from the incision. Which of the following actions should the nurse take?
Secure a clean diaper snugly across the newborn's penis.
Apply gentle pressure using a sterile dry gauze pad.
Rinse the newborn's penis with cool water.
Place petroleum jelly on the bleeding site.
The Correct Answer is B
Choice A rationale
Securing a clean diaper snugly across the newborn's penis might help manage minor bleeding but won't effectively address active oozing of bright red blood from a circumcision site.
Choice B rationale
Applying gentle pressure using a sterile dry gauze pad is the appropriate action to control bleeding. Applying direct pressure helps to stop the bleeding and allows for proper assessment of the wound.
Choice C rationale
Rinsing the newborn's penis with cool water might provide temporary relief but is not an effective method to control bleeding from a surgical site. It may also increase the risk of infection if not done sterilely.
Choice D rationale
Placing petroleum jelly on the bleeding site is typically done to prevent the diaper from sticking to the incision, but it is not sufficient to control active bleeding. .
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Correct Answer is A
Explanation
Choice A rationale
Fundus located to the right of the umbilicus requires intervention. This can indicate a full bladder, which can inhibit uterine contraction and increase the risk of postpartum hemorrhage.
Choice B rationale
A temperature of 37.8° C (100° F) is a common finding postpartum and usually does not require intervention unless it is accompanied by other signs of infection.
Choice C rationale
Deep tendon reflexes 2+ is a normal finding and does not require intervention. It indicates normal neuromuscular function.
Choice D rationale
A moderate amount of lochia rubra is expected postpartum and does not require intervention unless it is excessive or associated with other abnormal symptoms.
Correct Answer is C
Explanation
Choice A rationale
Maternal age of 21 years is not considered a significant risk factor for gestational diabetes. Typically, advanced maternal age (35 years or older) is considered a risk factor due to changes in insulin resistance that occur with age.
Choice B rationale
A fasting blood glucose of 72 mg/dL is within the normal range and does not indicate a risk for gestational diabetes. Gestational diabetes is usually diagnosed with fasting blood glucose levels higher than 95 mg/dL.
Choice C rationale
Previous newborn weighing 4.8 kg is a significant risk factor for gestational diabetes. Having a macrosomic (large) baby in a previous pregnancy is linked with an increased risk of developing gestational diabetes in subsequent pregnancies.
Choice D rationale
A prepregnancy BMI of 23 is within the normal range (18.5-24.9) and does not increase the risk of gestational diabetes. Higher BMI levels, particularly above 25, are associated with an increased risk.