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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale:
A white blood cell count of 15,000 does not necessarily indicate a severe infection. In newborns, WBC counts are typically higher than in adults, and they gradually decrease over the first few days after birth. A value of 15,000 falls within the normal range for a newborn and is not indicative of a severe infection.
Choice B rationale:
A white blood cell count of 15,000 is considered a normal range for a newborn. Newborns have higher WBC counts as a natural response to the stress of birth and exposure to the outside environment. The immune system is still developing, and elevated WBC counts are normal during this period.
Choice C rationale:
Assuming there are no other indications of lab error, such as abnormal results in other tests, it would be premature to label the WBC count as a lab error. Additionally, healthcare professionals should always consider the overall clinical picture before assuming a lab error based on a single result.
Choice D rationale:
There is no immediate need to call the doctor based solely on the WBC count of 15,000. Medical decisions should be made in the context of the newborn's overall clinical condition, and a single lab result does not warrant an immediate call to the doctor.
Correct Answer is C
Explanation
Choice A rationale:
Reporting the client's weight to the provider is not a priority in this situation. While weight is important, the immediate concern is the newborn's respiratory distress and the acidosis indicated by the blood gases.
Choice B rationale:
Selecting diagnostic studies for the primary health care is not the nurse's role. The primary health care provider will determine which diagnostic studies are needed based on the newborn's clinical presentation and assessment findings.
Choice C rationale:
Checking brachial pulses for the client's respiratory status is the appropriate action. In a newborn with respiratory distress, assessing peripheral perfusion, including brachial pulses, is crucial to monitor the circulation and oxygenation of tissues.
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