A nurse is caring for a client who is breastfeeding and tells the nurse that she is concerned about her newborn's hydration. Which of the following nursing observations is appropriate to use in evaluating the adequacy of the newborn's hydration?
The fit of the newborn's clothes.
The number of wet diapers per day.
How often the newborn cries.
The newborn's skin turgor.
The Correct Answer is B
Choice A rationale:
The fit of the newborn's clothes is not a reliable indicator of hydration. It may vary based on the clothing size or style and does not give a direct measure of the newborn's hydration status. This choice is not appropriate for evaluating hydration and is therefore incorrect.
Choice B rationale:
The number of wet diapers per day is an essential measure for assessing a newborn's hydration. In the first few days after birth, the baby should have at least one wet diaper for each day of life (e.g., one wet diaper on day one, two on day two, etc.). Afterward, the newborn should have around 6-8 wet diapers per day, which indicates adequate hydration. This choice is appropriate and the correct answer.
Choice C rationale:
How often the newborn cries can be influenced by various factors, including hunger, discomfort, or sleepiness. While crying can indicate the baby's needs, it is not a specific or accurate measure of hydration status. Therefore, this choice is not appropriate for evaluating hydration and is incorrect.
Choice D rationale:
The newborn's skin turgor is a measure of skin elasticity, commonly used in adults to assess hydration. However, it is not a reliable indicator of hydration in newborns, as their skin is more elastic and different from adult skin. Skin turgor is not a suitable parameter to evaluate newborn hydration, making this choice incorrect.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A rationale:
One ounce is equivalent to 29.57 ml (30 mls when rounded off to the nearest whole number). This conversion is essential in pediatric care, especially when administering medications to infants, as doses are often prescribed in milliliters.
Choice B rationale:
One ounce is equivalent to 29.57 ml (30 mls when rounded off to the nearest whole number). This conversion is essential in pediatric care, especially when administering medications to infants, as doses are often prescribed in milliliters.
Choice C rationale:
One ounce is equivalent to 29.57 ml (30 mls when rounded off to the nearest whole number). This conversion is essential in pediatric care, especially when administering medications to infants, as doses are often prescribed in milliliters.
Choice D rationale:
One ounce is equivalent to 29.57 ml (30 mls when rounded off to the nearest whole number). This conversion is essential in pediatric care, especially when administering medications to infants, as doses are often prescribed in milliliters.
Correct Answer is A
Explanation
Choice A rationale:
An apical pulse of 130/min in a newborn is within the normal range. The normal heart rate for a newborn is generally between 110 to 160 beats per minute (bpm). As the newborn's heart rate falls within this range, the nurse should document it as an expected finding and continue routine monitoring.
Choice B rationale:
Calling the neonatologist to assess the newborn for an apical pulse of 130/min is not warranted as it is a normal finding. The nurse should only notify the neonatologist if there are abnormal vital signs or concerning clinical signs.
Choice C rationale:
Asking another nurse to verify the heart rate is unnecessary in this scenario. The nurse can independently measure the apical pulse and document the finding as long as it falls within the normal range for newborns.
Choice D rationale:
Preparing the newborn for transport to the Neonatal Intensive Care Unit (NICU) is not indicated for a normal apical pulse rate. Transporting a newborn to the NICU is typically reserved for critical or unstable conditions. In this case, the normal heart rate of 130/min does not warrant NICU transport.
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