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 D
Explanation
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.
Correct Answer is C
Explanation
Choice A rationale:
The liver's job related to bilirubin is not changing conjugated bilirubin to unconjugated. Conjugated bilirubin is the water-soluble form of bilirubin that is excreted in bile and urine. Unconjugated bilirubin, on the other hand, is the fat-soluble form, which is transported to the liver and conjugated to become water-soluble. The conversion goes from unconjugated to conjugated, not the other way around.
Choice B rationale:
The liver's job related to bilirubin is not the synthesis of vitamin K. The liver is responsible for synthesizing clotting factors, including factors II (prothrombin), VII, IX, and X, but not vitamin K itself. Vitamin K is obtained from dietary sources or supplements and is essential for blood clotting.
Choice C rationale:
This choice is the correct answer. The liver's primary function related to bilirubin is changing unconjugated bilirubin to conjugated bilirubin. As mentioned earlier, unconjugated bilirubin is produced from the breakdown of heme in old red blood cells, and it needs to be processed in the liver to become water-soluble and eventually excreted in bile and urine.
Choice D rationale:
The liver's job related to bilirubin does not involve the removal of meconium. Meconium is the first stool passed by a newborn, and its elimination is unrelated to the liver's function in processing bilirubin.
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