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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 D

Explanation

Choice A rationale

Auscultating the newborn’s bowel sounds is important for assessing gastrointestinal function, but it is not the first priority in managing a newborn with neonatal abstinence syndrome (NAS). Initial care should focus on stabilizing the newborn and addressing withdrawal symptoms.

Choice B rationale

Swaddling the newborn in blankets can help provide comfort and reduce excessive stimulation, which is beneficial for newborns with NAS. However, it is not the first priority. The primary focus should be on assessing and stabilizing the newborn’s vital signs.

Choice C rationale

Weighing the newborn’s wet diaper is important for monitoring fluid balance and hydration status, but it is not the first priority in managing NAS. Initial care should focus on stabilizing the newborn and addressing withdrawal symptoms.

Choice D rationale

Determining the newborn’s respiratory rate is the first priority in managing a newborn with NAS. Assessing and stabilizing the newborn’s vital signs, including respiratory rate, is crucial to ensure the newborn’s immediate health and safety.

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.

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