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.
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Correct Answer is C
Explanation
Choice A rationale
Agitation is not a common adverse effect of magnesium sulfate therapy. It is more likely to be caused by other factors.
Choice B rationale
Polyuria, or excessive urination, is not a common adverse effect of magnesium sulfate therapy. It is more likely to be caused by other factors.
Choice C rationale
Hyporeflexia, or diminished reflexes, is a significant adverse effect of magnesium sulfate therapy. It indicates magnesium toxicity and requires immediate attention.
Choice D rationale
Tachypnea, or rapid breathing, is not a common adverse effect of magnesium sulfate therapy. It is more likely to be caused by other factors.
Correct Answer is D
Explanation
Choice A rationale
Amniotic fluid with meconium noted can indicate fetal distress, but it is not the most immediate priority compared to fetal heart tones.
Choice B rationale
A maternal temperature of 38.3°C (101°F) can indicate infection, but it is not the most immediate priority compared to fetal heart tones.
Choice C rationale
Foul-smelling vaginal discharge can indicate infection, but it is not the most immediate priority compared to fetal heart tones.
Choice D rationale
Fetal heart tones of 98/min indicate fetal bradycardia, which is a sign of fetal distress and requires immediate intervention to ensure the well-being of the fetus.