The nurse is caring for an 18-hour-old newborn who has not voided for the first time yet. What is the nurse's priority action?
Notifying the provider immediately.
Pressing on the bladder to prevent urine retention.
Administering IV fluid.
Documenting and continuing monitoring.
The Correct Answer is D
Choice A rationale:
Notifying the provider immediately may be an appropriate action in certain urgent situations. However, for a newborn who has not voided for the first time yet, it is not an immediate emergency. The priority is to assess the newborn's condition further before notifying the provider.
Choice B rationale:
Pressing on the bladder to prevent urine retention is not a recommended action. Applying pressure on the newborn's bladder can be harmful and is not a standard nursing practice.
Choice C rationale:
Administering IV fluid is not the priority action for a newborn who has not voided. Newborns usually receive sufficient hydration from breastfeeding or formula feeding, and administering IV fluid without proper indication can lead to potential complications.
Choice D rationale:
Documenting and continuing monitoring is the correct priority action in this situation. Newborns often take some time to pass their first urine, and it is considered normal for them to have delayed voiding within the first 24 hours after birth. The nurse should document the absence of voiding and monitor the newborn for any signs of distress or abnormalities. If the newborn's condition worsens or if there are other concerning symptoms, then notifying the provider may be necessary.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale:
The nurse should not report the client's Hemoglobin level first to the primary health care because it falls within the normal range of 14 to 24 g/dL for a newborn. Therefore, it is not an immediate concern.
Choice B rationale:
The nurse should first report the client's Chest x-ray results to the primary health care. The diffuse pattern of radiopaque areas bilaterally on the chest x-ray suggests possible respiratory distress or other respiratory issues in the newborn. This finding requires immediate attention and intervention to ensure proper respiratory function.
Choice C rationale:
The nurse should not report the client's Glucose level first to the primary health care as 40 mg/dL is within the normal range of 30 to 60 mg/dL for a newborn. Though it is on the lower side, it is not critically low, and there are more urgent concerns to address.
Correct Answer is C
Explanation
Choice A rationale:
Wearing a supportive bra can actually help to manage engorgement, so it's not recommended to avoid wearing one during the day.
Choice B rationale:
Cold compresses are typically applied after feeding to reduce swelling, not before. Applying them before might hinder the milk let-down reflex.
Choice C rationale:
Frequent feeding can help to alleviate engorgement by ensuring that the breasts are being emptied regularly.
Choice D rationale:
Stopping breastfeeding until finishing antibiotics is not advisable, as it can lead to decreased milk supply and potential issues with engorgement. Antibiotics prescribed by a healthcare provider are usually safe to take while breastfeeding, and interrupting breastfeeding can exacerbate the engorgement problem. This choice is not appropriate for managing breast engorgement and is therefore incorrect.
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