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. .
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A rationale
Placing a newborn in the right lateral position is not recommended as it increases the risk of suffocation and sudden infant death syndrome (SIDS)4.
Choice B rationale
Placing a newborn in the left lateral position is also not recommended for the same reasons as the right lateral position.
Choice C rationale
Placing a newborn in the prone position (on their stomach) significantly increases the risk of SIDS and is not recommended.
Choice D rationale
Placing a newborn in the supine position (on their back) is the safest position for sleep and is recommended to reduce the risk of SIDS4.
Correct Answer is {"dropdown-group-1":"A","dropdown-group-2":"D"}
Explanation
The nurse should first address the client’sA. Elevated blood pressure, followed by the client’sD. Visual disturbances.
Explanation:
- Elevated blood pressure: This is the most critical issue to address first because it poses an immediate risk to both the mother and the fetus. Severe hypertension can lead to complications such as preeclampsia, eclampsia, or placental abruption. The provider has already prescribed labetalol to manage the blood pressure, which is a priority intervention.
- Visual disturbances: These can be a sign of worsening preeclampsia, which requires close monitoring and prompt intervention. Addressing visual disturbances is crucial to prevent further complications.
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