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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 C

Explanation

Choice A rationale

Verifying that the newborn is Rh-negative is not necessary for administering Rh(D) immune globulin. The medication is given to Rh-negative mothers to prevent Rh sensitization, regardless of the newborn’s Rh status.

Choice B rationale

A positive Coombs test indicates that the mother has already been sensitized to Rh-positive blood cells, making Rh(D) immune globulin ineffective in preventing sensitization.

Choice C rationale

Administering Rh(D) immune globulin within 72 hours after birth is crucial to prevent Rh sensitization in future pregnancies. This timing ensures that the mother’s immune system does not produce antibodies against Rh-positive blood cells.

Choice D rationale

Rh(D) immune globulin is typically administered intramuscularly, not into the abdomen. The preferred sites are the deltoid muscle or the anterolateral aspect of the thigh.

Correct Answer is B

Explanation

Choice A rationale

Placing the newborn supine and applying pressure to the soles of the feet is not the correct method to elicit the Babinski reflex. This action does not stimulate the appropriate nerve pathways involved in the reflex.

Choice B rationale

Stroking upward on the lateral aspect of the sole of the newborn’s foot is the correct method to elicit the Babinski reflex. This action stimulates the plantar reflex, causing the big toe to extend upward and the other toes to fan out.

Choice C rationale

Pulling the newborn up by the wrist from a supine position is used to elicit the traction response, not the Babinski reflex. The traction response involves the newborn flexing their arms and attempting to lift their head.

Choice D rationale

Touching the corner of the newborn’s mouth elicits the rooting reflex, not the Babinski reflex. The rooting reflex causes the newborn to turn their head toward the stimulus and open their mouth.

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