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.
Free Nursing Test Bank
- Free Pharmacology Quiz 1
- Free Medical-Surgical Quiz 2
- Free Fundamentals Quiz 3
- Free Maternal-Newborn Quiz 4
- Free Anatomy and Physiology Quiz 5
- Free Obstetrics and Pediatrics Quiz 6
- Free Fluid and Electrolytes Quiz 7
- Free Community Health Quiz 8
- Free Promoting Health across the Lifespan Quiz 9
- Free Multidimensional Care Quiz 10
View Related questions
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.
Correct Answer is B
Explanation
Choice A rationale
Limiting the client’s daily fluid intake is not recommended. Adequate hydration is important for clients with mastitis to help clear the infection and maintain milk supply.
Choice B rationale
Encouraging the client to continue to breastfeed is recommended. Breastfeeding helps to empty the breasts and reduce milk stasis, which can alleviate symptoms of mastitis.
Choice C rationale
Preparing the client for an abdominal sonogram is not relevant to the management of mastitis. Mastitis is typically diagnosed based on clinical symptoms and physical examination.
Choice D rationale
Encouraging the client to wear a bra that is loose fitting is not recommended. A well-fitting, supportive bra can help to reduce discomfort and support the breasts during mastitis.