A nurse is caring for a 1-month-old infant who has manifestations of severe dehydration and a prescription for parenteral fluid therapy. The guardian asks, "What are the indication that my baby needs an IV?" Which of the following responses should the nurse make?

"Your baby needs an IV because she is breathing slower than normal."

"Your baby needs an IV because her heart rate is decreased."

"Your baby needs an IV because her fontanels are bulging."

"Your baby needs an IV because she is not producing tears."

Answer and Explanation

The Correct Answer is D

Rationale:

A. "Your baby needs an IV because she is breathing slower than normal.": Severe dehydration is more likely to cause tachypnea rather than slower breathing, as the body attempts to compensate for metabolic acidosis.

B. "Your baby needs an IV because her heart rate is decreased.": Severe dehydration in infants usually results in tachycardia due to hypovolemia. A decreased heart rate may indicate impending cardiovascular collapse, which is a late and severe sign.

C. "Your baby needs an IV because her fontanels are bulging.": Bulging fontanels suggest increased intracranial pressure, not dehydration. Dehydration typically causes sunken fontanels due to decreased fluid volume.

D. "Your baby needs an IV because she is not producing tears.": Absence of tears during crying is a classic sign of significant dehydration in infants. This indicates reduced fluid volume and supports the need for IV therapy to restore hydration.

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Correct Answer is B

Explanation

Rationale:

A. “Staff will apply identification bands to my baby after her first bath.": Identification bands are applied immediately after birth to ensure proper identification and prevent abduction, not after the first bath. Waiting could increase safety risks.

B. "I will not publish a public announcement about my baby's birth.": Limiting public announcements, such as on social media, reduces the risk of unwanted attention and potential abduction. This demonstrates understanding of newborn security measures.

C. "I can remove my baby's identification band as long as she is in my room.": Identification bands must remain on the newborn at all times to maintain safety and prevent misidentification or abduction. Removing them is unsafe.

D. "I can leave my baby in my room while I walk in the hallway.": Leaving a newborn unattended, even briefly, increases the risk of abduction and is against safety protocols. Constant supervision or staff assistance is required.

A. Blood pressure B. Skin temperature C. Fundal assessment D. Bleeding

Correct Answer is {"A":{"answers":"A"},"B":{"answers":"B"},"C":{"answers":"A"},"D":{"answers":"A"}}

Explanation

Blood pressure: At 2100, the client’s BP was 90/56 mm Hg, indicating hypotension likely from postpartum hemorrhage. By 2115, BP increased to 108/72 mm Hg, showing improved hemodynamic stability after interventions such as fundal massage, oxytocin administration, and bladder emptying.
Skin temperature: At both 2100 and 2115, the client’s skin remained cool to the touch. This could indicate ongoing peripheral vasoconstriction or residual hypoperfusion, suggesting that although circulation improved, thermoregulation and peripheral perfusion have not fully normalized.
Fundal assessment: Initially, the fundus was boggy, deviated to the right, and 2 cm above the umbilicus, indicating uterine atony worsened by bladder distention. After catheterization and uterotonic therapy, the fundus became midline, firm, and at the level of the umbilicus, which is expected postpartum and reduces bleeding risk.
Bleeding: At 2100, there was heavy lochia rubra saturating a perineal pad in 20 min with passage of a large clot. At 2115, bleeding decreased to a moderate amount of lochia rubra with a few pea-sized clots, indicating that hemorrhage control measures were effective.

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A nurse is caring for a 1-month-old infant who has manifestations of severe dehydration and a prescription for parenteral fluid therapy. The guardian asks, "What are the indication that my baby needs an IV?" Which of the following responses should the nurse make?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is reviewing the facility's safety protocols concerning newborn abduction with the parent of a newborn. Which of the following client statements indicates an understanding of the teaching?

Correct Answer is B

Explanation

A nurse is caring for a client who is 1 hr postpartum. Exhibits For each assessment finding, click to specify if the finding indicates the client's condition has improved or remains unchanged. There must be at least 1 selection in every row. There does not need to be a selection in every column.

Correct Answer is {"A":{"answers":"A"},"B":{"answers":"B"},"C":{"answers":"A"},"D":{"answers":"A"}}

Explanation

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