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
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A: Elastic stockings are used to promote venous return and decrease the risk of thrombosis, but they are not the primary preventive measure against thrombophlebitis.
B: Warm, moist packs may provide comfort and reduce localized swelling, but they do not prevent thrombophlebitis and are not a standard preventive measure.
C: Early and frequent ambulation is the most effective way to prevent thrombophlebitis. It enhances blood flow and prevents stasis, which is a major risk factor for the development of thrombophlebitis.
D: NSAIDs can be used to manage pain and inflammation but are not used as a preventive measure for thrombophlebitis in the postpartum setting.
Correct Answer is D
Explanation
A. Upper abdominal pain could indicate a variety of issues, including gastrointestinal upset or muscle soreness from labor, but it is not specific to a puerperal infection.
B. Bradycardia (slow heart rate) is not typically associated with a puerperal infection.
C. Hypothermia (low body temperature) is not a typical sign of a puerperal infection.
D. Foul-smelling lochia can be indicative of an infection, as an unpleasant odor may be associated with bacterial growth in the uterine cavity. This is a concerning sign and should be further evaluated.
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