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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

Nursing the baby for 5 to 10 minutes on each breast may not be sufficient for the baby to receive the hindmilk, which is rich in fat and essential for growth.

Choice B rationale

Applying vitamin E oil to the nipples after each feeding is not recommended as it can cause irritation and is not necessary for nipple care.

Choice C rationale

Laying the baby on a pillow at the level of the breast helps ensure proper positioning and latch, which is crucial for effective breastfeeding and preventing nipple soreness.

Choice D rationale

Ensuring that just the nipple is in the baby’s mouth is incorrect. The baby should latch onto the areola, not just the nipple, to ensure effective milk transfer and prevent nipple pain.

Correct Answer is D

Explanation

Choice A rationale

Assessing the client’s socioeconomic status is important but not the primary action the nurse should take in the maternal newborn unit. The focus should be on providing unbiased teachings based on the client’s needs.

Choice B rationale

Collecting a dietary history is important but not the primary action the nurse should take in the maternal newborn unit. The focus should be on providing unbiased teachings based on the client’s needs.

Choice C rationale

Determining the best method of contraception for the client is important but not the primary action the nurse should take in the maternal newborn unit. The focus should be on providing unbiased teachings based on the client’s needs.

Choice D rationale

Performing unbiased teachings based on the client’s needs is the primary action the nurse should take in the maternal newborn unit. This ensures that the client receives accurate and relevant information tailored to their specific situation.

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