A nurse is collecting data on a newborn who is 1 day old.Which of the following findings is a manifestation of dehydration?
Presence of acrocyanosis.
Capillary refill greater than 3 seconds.
Voided four times in the past 24 hours.
Flat soft anterior fontanel.
The Correct Answer is B
Choice A rationale
Acrocyanosis is a common finding in newborns and is not a sign of dehydration. It usually resolves on its own.
Choice B rationale
A capillary refill time greater than 3 seconds can indicate dehydration in a newborn. It suggests poor perfusion and fluid status.
Choice C rationale
Voiding four times in the past 24 hours is within the normal range for a newborn and does not indicate dehydration.
Choice D rationale
A flat soft anterior fontanel is normal in newborns and does not indicate dehydration. A sunken fontanel would be a sign of dehydration.
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Correct Answer is D
Explanation
Choice A rationale
Amniotic fluid with meconium noted can indicate fetal distress, but it is not the most immediate priority compared to fetal heart tones.
Choice B rationale
A maternal temperature of 38.3°C (101°F) can indicate infection, but it is not the most immediate priority compared to fetal heart tones.
Choice C rationale
Foul-smelling vaginal discharge can indicate infection, but it is not the most immediate priority compared to fetal heart tones.
Choice D rationale
Fetal heart tones of 98/min indicate fetal bradycardia, which is a sign of fetal distress and requires immediate intervention to ensure the well-being of the fetus.
Correct Answer is D
Explanation
Choice A rationale
Assessing the client’s socioeconomic status is important but not the primary action the nurse should take in the maternal newborn unit. The focus should be on providing unbiased teachings based on the client’s needs.
Choice B rationale
Collecting a dietary history is important but not the primary action the nurse should take in the maternal newborn unit. The focus should be on providing unbiased teachings based on the client’s needs.
Choice C rationale
Determining the best method of contraception for the client is important but not the primary action the nurse should take in the maternal newborn unit. The focus should be on providing unbiased teachings based on the client’s needs.
Choice D rationale
Performing unbiased teachings based on the client’s needs is the primary action the nurse should take in the maternal newborn unit. This ensures that the client receives accurate and relevant information tailored to their specific situation.