Newborn Nursing Care Q 22
A nurse is assessing a newborn infant following circumcision and notes that the circumcised area is red with a small amount of bloody drainage. Which of the following nursing actions would be most appropriate?
A. Document the findings
B. Contact the physician
C. Circle the amount of bloody drainage on the dressing and reassess in 30 minutes
D. Reinforce the dressing
Correct Answer: A. Document the findings. The penis is normally red during the healing process.
Option A: Close observation of the circumcision site during the first few hours is necessary to determine if there is a complication. A yellow exudate may be noted after 24 hours, and this is a part of normal healing. This should not be washed away because it serves a protective function. The nurse would expect that the area would be red with a small amount of bloody drainage. Because the findings identified in the question are normal, the nurse would document the assessment. Additionally, document if the infant is voiding after the procedure to ascertain that the urethra is not occluded. Instruct the parents to keep the site free from feces and covered in petrolatum until healing is complete. If the infant cries constantly and if there is redness or tenderness due to pain, it should be reported to the physician.
Option B: Hemorrhage, infection, and urethral fistula formation are rare complications that can occur from circumcision. If bleeding is not controlled, then the blood vessel may need to be ligated, and the nurse would contact the physician.
Option C: A circumcision site that appears red is normal as long as it does not have a strong odor or strong discharge.
Option D: If the bleeding is excessive, the nurse would apply gentle pressure with sterile gauze.