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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 A

Explanation

Choice A rationale

Repositioning the newborn every 2 to 3 hours is essential during phototherapy to ensure that all areas of the skin are exposed to the light. This helps in the effective breakdown of bilirubin and prevents pressure sores.

Choice B rationale

Monitoring the newborn’s blood glucose level every 2 hours is not a standard intervention for phototherapy. While monitoring glucose levels is important in certain conditions, it is not directly related to the management of hyperbilirubinemia.

Choice C rationale

Applying a water-based ointment to the newborn’s skin every 4 to 6 hours is not recommended during phototherapy. Ointments can block the light from reaching the skin, reducing the effectiveness of the treatment.

Choice D rationale

Giving the newborn 30 mL of distilled water after each feeding is not a recommended practice. Hydration is important, but it should be done through breastfeeding or formula feeding, not distilled water.

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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