A nurse is collecting data from a newborn who is receiving phototherapy. Which of the following findings is an indication of dehydration?
Bulging anterior fontanel
Decreased urine specific gravity
Bounding pulses
Decreased skin turgor
The Correct Answer is D
A. A bulging anterior fontanel suggests increased intracranial pressure, not dehydration.
B. Decreased urine specific gravity can occur with hydration or dilute urine, and it is not specific to dehydration.
C. Bounding pulses may be present in various conditions but are not a direct sign of dehydration.
D. Decreased skin turgor is a classic sign of dehydration in both infants and adults. It indicates a deficit of body fluids.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. Upper abdominal pain could indicate a variety of issues, including gastrointestinal upset or muscle soreness from labor, but it is not specific to a puerperal infection.
B. Bradycardia (slow heart rate) is not typically associated with a puerperal infection.
C. Hypothermia (low body temperature) is not a typical sign of a puerperal infection.
D. Foul-smelling lochia can be indicative of an infection, as an unpleasant odor may be associated with bacterial growth in the uterine cavity. This is a concerning sign and should be further evaluated.
Correct Answer is D
Explanation
A. administering misoprostol, may be indicated in postpartum care, but it is not the first priority in this situation. The immediate concern is excessive bleeding, which should be addressed first.
B. increasing maintenance IV fluid, is not the first action to take. While fluid management is important, it is not the priority when the client is experiencing excessive postpartum bleeding.
C. performing perineal hygiene, is important for overall hygiene, but it is not the first action to take when the client is experiencing excessive bleeding. Controlling bleeding takes precedence.
D. performing fundal assessment and massage, is the first priority. This helps assess for uterine atony (failure of the uterus to contract), a common cause of postpartum hemorrhage. Massage can stimulate uterine contractions and help control bleeding.
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