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.

Answer and Explanation

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.

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Correct Answer is C

Explanation

Choice A rationale:

Activating respiratory arrest procedures is not necessary in this situation. The newborn's respiratory rate, although slightly elevated, does not indicate respiratory arrest. Instead, such procedures are reserved for situations where the newborn has stopped breathing or is in acute respiratory distress.

Choice B rationale:

Requesting an order for supplemental oxygen may be premature. The newborn's respiration rate of 44/min, although shallow with periods of apnea, is still within the normal range for a newborn. Providing supplemental oxygen should be considered when the newborn is showing signs of significant respiratory distress or if oxygen saturation levels are low.

Choice C rationale:

The most appropriate action in this scenario is to continue routine monitoring of the newborn's respiratory rate and overall condition. Newborns often exhibit irregular breathing patterns, including periods of apnea, especially in the first few hours after birth. As long as the newborn's color, heart rate, and overall appearance are stable, routine monitoring is appropriate.

Choice D rationale:

There is no need to report the observation to the charge nurse immediately, as the newborn's respiratory rate and pattern fall within the expected range for a 12-hour-old newborn.

Reporting should be considered when there are significant deviations from the norm or if the newborn's condition deteriorates.

A. Metabolic alkalosis. B. Metabolic acidosis. C. The infant is hungry. D. The infant is overstimulated.

Correct Answer is B

Explanation

A. This condition typically results from excessive loss of acid, often due to vomiting or diuretics. It is not the most likely concern in a cold environment with an infant who has been crying and kicking.

B. A cold environment can lead to nonshivering thermogenesis in newborns, where they metabolize brown fat to generate heat. This process can lead to increased lactic acid production, potentially causing metabolic acidosis. The infant's fatigue following crying and kicking may indicate that the body has expended significant energy to stay warm, making metabolic acidosis a priority concern.

C. While hunger could be a reason for crying, it is not the priority concern in this scenario where environmental cold and fatigue are present.

D. Overstimulation might cause crying, but the environmental cold and subsequent risk of metabolic acidosis are more critical concerns in this context.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is collecting data from a newborn who is 12 hours old. His respiration rate is 44/min, shallow, with periods of apnea lasting up to 5 seconds. Which of the following actions should the nurse take?

Correct Answer is C

Explanation

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Correct Answer is B

Explanation

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