The nurse notes swelling in the scrotum of a newborn infant. Transillumination reveals a reddish-yellow reflection. What action by the nurse is best?

Correct Answer: A

Rationale: When the nurse assesses a swollen scrotum, it is important to determine that the scrotal sac does not contain entrapped bowel or a mass. Transillumination can determine the presence of a mass when the light directed at the scrotum does not produce a reflection. A reddish-yellow reflection indicates fluid, which will be reabsorbed on its own. The nurse should document the findings and reassure the parents. No further action is needed.

Correct Answer: B

Rationale: Several options exist for nail care to keep the infant from scratching her face. The nails can be cut, but there is a risk of damaging the delicate skin around the nail. This is best done while the baby sleeps. Letting the nails break off is not a good option, as the child may injure herself before they break. Covering the hands with mittens or a tee shirt is a possible option, but does not allow the child to suck on the fingers for self-soothing. The best option is to file the nails gently with a fine-grained emery board.

Correct Answer: A

Rationale: The nurse should assess for the first voiding after a circumcision to evaluate for urinary obstruction related to injury or swelling. Slight blood on the diaper would be expected. Some swelling may occur and does not cause concern unless it blocks the urethra. After a procedure, it is normal for an infant to wish to be held and comforted.

Correct Answer: C

Rationale: The extrusion reflex is elicited by touching the tip of the infant's tongue. The tongue should protrude outward. Palmar grasp is detected by placing a small object in the infant's hand. Stroking the side of the cheek should result in the rooting reflex. Turning the head and watching the position of the extremities is part of the tonic neck or fencing reflex.

Correct Answer: D

Rationale: In the context of pharmacology and nursing care of newborns, understanding infant behavior is crucial for providing optimal care. The correct answer, option D - Response to stimulation, is the best choice for assessing infant behavior. This is because a newborn's response to various stimuli can provide valuable insights into their neurological development, sensory processing, and overall well-being. Option A, Ease of learning to nurse, is incorrect because nursing ability is not a reliable indicator of infant behavior and may be influenced by factors like feeding techniques or maternal factors rather than the infant's behavior itself. Option B, Length of sleeping periods, is also incorrect as it only provides information on one aspect of infant behavior (sleep patterns) and does not give a comprehensive view of their overall behavior and responses. Option C, Presence of reflex activity, while important in assessing newborns, does not capture the full range of behaviors that can provide insight into their neurological functioning and responses to the environment. Educationally, understanding how to assess infant behavior accurately is essential for nurses caring for newborns as it can help in early identification of any neurological or developmental issues, guide appropriate interventions, and promote optimal growth and development in these vulnerable patients. By choosing the correct option, nurses can tailor their care based on the individual needs and responses of each newborn, ultimately improving outcomes and promoting overall health and well-being.