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
A temperature of 37.8°C (100°F) 18 hours postpartum is slightly elevated but not necessarily indicative of a serious issue. It may require monitoring but is not the most urgent concern.
Choice B rationale
Abdominal pain during breastfeeding 8 hours postpartum is a common experience due to uterine contractions. While it may cause discomfort, it is not typically an urgent concern.
Choice C rationale
Not having a bowel movement 24 hours postpartum is not uncommon and does not usually require immediate attention. It can be addressed with dietary changes and other interventions.
Choice D rationale
Saturating one perineal pad over 2 hours 6 hours postpartum in a G5P4 client indicates a potential risk of postpartum hemorrhage. This is a more urgent concern that requires immediate assessment and intervention to prevent complications.
Correct Answer is C
Explanation
Choice A rationale
Avocados are a good source of healthy fats, vitamins, and minerals, but they are not particularly high in calcium. They are beneficial for overall health but not specifically for increasing calcium intake.
Choice B rationale
Peanut butter is a good source of protein and healthy fats, but it is not a significant source of calcium. It can be part of a balanced diet but will not substantially increase calcium levels.
Choice C rationale
Yogurt is an excellent source of calcium, which is essential for bone health, especially during pregnancy. It also provides probiotics, which can aid in digestion and overall health.
Choice D rationale
Long grain rice is a good source of carbohydrates and some vitamins, but it is not high in calcium. It can be part of a balanced diet but will not significantly contribute to calcium intake.