The nurse is assessing a 2-day-old male infant that has been circumcised. Which finding requires immediate intervention?
1. The umbilical cord clamp has been removed.
2. The mother is ready to breastfeed on demand.
3. The infant maintains temperature when wrapped in a blanket.
4. The infant has had a dry diaper since the circumcision procedure.
4
Explanation:
1. The umbilical cord clamp should be removed between 24 and 48 hours after birth to reduce the chance of tension injury to the area.
2. This is a positive action that represents the mother's readiness to care for her infant at home.
3. The infant should be able to maintain body temperature without the presence of the radiant warmer.
4. If the infant has not voided since the circumcision procedure, further assessment should be done to determine if a penile injury and/or edema is preventing urinary flow.
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A pregnant woman diagnosed with diabetes should be instructed to do which of the following?
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The nurse is observing a client obtain a capillary blood specimen for glucose and notes that the client actively squeezes the finger after piercing it with a lancet and then places a drop of blood on the test strip. The meter shows the blood glucose as 126 mg/dl. How does the nurse interpret these results?
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The nurse notes a client's warfarin (Coumadin) level is 7 mcg/mL. Which action should the nurse take?
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