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A nurse is collecting data on a newborn who is 1 day old.Which of the following findings is a manifestation of dehydration?

A.

Presence of acrocyanosis.

B.

Capillary refill greater than 3 seconds.

C.

Voided four times in the past 24 hours.

D.

Flat soft anterior fontanel.

Answer and Explanation

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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View Related questions

Correct Answer is D

Explanation

Choice A rationale

Serum bilirubin is not the priority test for hyperemesis gravidarum. It is more relevant for assessing liver function and jaundice.

Choice B rationale

Liver enzymes may be elevated in hyperemesis gravidarum, but they are not the priority test. The primary concern is dehydration and electrolyte imbalance.

Choice C rationale

A CBC can provide information on the client’s overall health, but it is not the priority test for hyperemesis gravidarum. The focus should be on assessing hydration status.

Choice D rationale

Urinalysis for ketones is the priority test because it helps assess the severity of dehydration and malnutrition. The presence of ketones indicates that the body is breaking down fat for energy, which is a sign of inadequate caloric intake.

Correct Answer is D

Explanation

Choice A rationale

Diuresis, or increased urine production, is not a common adverse effect of nalbuphine hydrochloride. This medication is an opioid analgesic used for pain relief during labor.

Choice B rationale

Fever is not a typical adverse effect of nalbuphine hydrochloride. Fever may indicate an infection or other underlying condition that needs to be addressed separately.

Choice C rationale

Diarrhea is not a common adverse effect of nalbuphine hydrochloride. Opioids, including nalbuphine, are more likely to cause constipation rather than diarrhea.

Choice D rationale

Sedation is a known adverse effect of nalbuphine hydrochloride. As an opioid analgesic, it can cause drowsiness and sedation, which is important to monitor in laboring clients to ensure their safety and well-being.

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