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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 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.

Correct Answer is C

Explanation

Choice A rationale

Administering NSAIDs every 4 to 6 hours is not a primary measure to prevent thrombophlebitis. NSAIDs are used for pain relief and inflammation reduction, but they do not directly prevent blood clots.

Choice B rationale

Applying elastic stockings before the client gets out of bed can help prevent blood clots by promoting blood flow in the legs. However, this measure alone is not sufficient to prevent thrombophlebitis.

Choice C rationale

Ambulation, or walking, is one of the most effective measures to prevent thrombophlebitis. It promotes circulation and prevents blood from pooling in the legs, reducing the risk of clot formation.

Choice D rationale

Applying warm, moist packs to the client’s lower legs can help relieve pain and inflammation but does not directly prevent thrombophlebitis. This measure is more supportive rather than preventive.

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