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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

Administering oxygen may help with symptoms like headache and weakness, but it does not address the underlying issue of poor circulation and potential shock. Elevating the legs is more effective in improving blood flow to vital organs.

Choice B rationale

Offering an ice pack is not appropriate for the symptoms described. The client is showing signs of shock, and an ice pack would not address the underlying issue.

Choice C rationale

Providing a warm blanket may offer comfort, but it does not address the symptoms of shock. Elevating the legs is a more direct intervention to improve circulation and stabilize the client.

Choice D rationale

Elevating the client’s legs helps improve venous return to the heart, increasing cardiac output and stabilizing blood pressure. This is a critical intervention for a client showing signs of shock.

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.

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