The nurse is ready to perform a discharge assessment for a 2-day-old male infant that has been circumcised. Which of the following findings require immediate intervention?
1. The umbilical cord clamp has been removed.
2. The infant has had a dry diaper since the circumcision procedure.
3. The mother is ready to breastfeed on demand.
4. The infant maintains temperature when wrapped in a blanket.
Correct Answer: 2
Rationale 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.
Rationale 2: 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.
Rationale 3: This is a positive action that represents the mother's readiness to care for her infant at home.
Rationale 4: The infant should be able to maintain body temperature without the presence of the radiant warmer.
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