A nurse is collecting data from a newborn who is receiving phototherapy. Which of the following findings is an indication of dehydration?

Bulging anterior fontanel

Decreased urine specific gravity

Bounding pulses

Decreased skin turgor

Answer and Explanation

The Correct Answer is D

A.   A bulging anterior fontanel suggests increased intracranial pressure, not dehydration.
B.   Decreased urine specific gravity can occur with hydration or dilute urine, and it is not specific to dehydration.
C.   Bounding pulses may be present in various conditions but are not a direct sign of dehydration.
D.   Decreased skin turgor is a classic sign of dehydration in both infants and adults. It indicates a deficit of body fluids.

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Correct Answer is B

Explanation

A. Applying an antiseptic after the puncture can be done to prevent infection, but it is not the initial step.
B. Warming the newborn's heel helps to increase blood flow, making the collection process more effective and less painful.
C. The puncture should be made on the outer aspect of the newborn's heel, where there is a good blood supply.
D. After the puncture, it is important to apply pressure to the site to stop bleeding, typically using a gauze pad or cotton ball.

A. Administer the medication into the deltoid muscle. B. Check the mother's Rh factor prior to administration. C. Administer the medication 12 hr after birth. D. Administer the medication with a 25 gauge needle.

Correct Answer is D

Explanation

A: Administering the medication into the deltoid muscle is not recommended for newborns due to their underdeveloped muscle mass and the potential for injury. The vastus lateralis muscle in the thigh is the preferred site for intramuscular injections in infants.

B: Checking the mother's Rh factor is not directly related to the administration of phytonadione, which is given to prevent vitamin K deficiency bleeding in the newborn, a condition unrelated to the mother's Rh factor.

C: Administering the medication 12 hours after birth is not the standard practice. Phytonadione is typically given within the first hour after birth to ensure prompt prevention of hemorrhagic disease of the newborn.

D: Administering the medication with a 25 gauge needle is appropriate as it is small enough to cause minimal discomfort and large enough to ensure proper delivery of the medication into the infant's muscle tissue.

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A nurse is collecting data from a newborn who is receiving phototherapy. Which of the following findings is an indication of dehydration?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is B

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Correct Answer is D

Explanation

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