Page 853 - Saunders Comprehensive Review For NCLEX-RN

occur, antibiotics may be necessary. Options 2, 3, and 4 are not the most appropriate
nursing interventions for an umbilical cord infection as described in the question.
Test-Taking Strategy: Note the strategic words, most appropriate. Focus on the
clinical manifestations provided in the question to assist in answering. Noting the
word discharge in the question will assist in directing you to the option that indicates
that the newborn needs to be seen by the PHCP.
Level of Cognitive Ability: Applying
Client Needs: Physiological Integrity
Integrated Process: Nursing Process—Implementation
Content Area: Maternity: Newborn
Health Problem: Newborn: Infections
Priority Concepts: Clinical Judgment; Infection
Reference: McKinney et al. (2018), pp. 468, 473-474.

271. Answer: 2

Rationale: The highest priority on admission to the nursery for a newborn with a
low Apgar score is the airway, which would involve preparing respiratory
resuscitation equipment and oxygen. The remaining options are also important,
although they are of lower priority. The newborn would be placed on an apnea and
cardiorespiratory monitor. Setting up an intravenous line with 5% dextrose in water
would provide circulatory support. The radiant warmer would provide an external
heat source, which is necessary to prevent further respiratory distress.
Test-Taking Strategy: Note the strategic words, highest priority. This question asks
you to prioritize care on the basis of information about a newborn’s condition. Use
the ABCs—airway, breathing, and circulation. A method of planning for airway
support is to have the resuscitation bag connected to an oxygen source.
Level of Cognitive Ability: Analyzing
Client Needs: Physiological Integrity
Integrated Process: Nursing Process—Planning
Content Area: Complex Care: Emergency Situations/Management
Health Problem: Newborn: Respiratory Problems
Priority Concepts: Clinical Judgment; Gas Exchange
Reference: McKinney et al. (2018), p. 326.

272. Answer: 3

Rationale: The penis is normally red during the healing process after
circumcision. A yellow exudate may be noted in 24 hours, and this is part of normal
healing. The nurse would expect that the area would be red with a small amount of
bloody drainage. Only if the bleeding were excessive would the nurse apply gentle
pressure with a sterile gauze. If bleeding cannot be controlled, the blood vessel may
need to be ligated, and the nurse would notify the PHCP. Because the findings
identified in the question are normal, the nurse would document the assessment
findings.
Test-Taking Strategy: Note the strategic words, most appropriate, and focus on the
assessment findings in the question. This should assist in directing you to the correct

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