The nurse is caring for an 18-hour-old newborn who has not voided for the first time yet. What is the nurse's priority action?
Notifying the provider immediately.
Pressing on the bladder to prevent urine retention.
Administering IV fluid.
Documenting and continuing monitoring.
The Correct Answer is D
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["B","C","D","E"]
Explanation
Choice A rationale:
Drying the baby thoroughly is not directly related to assessing the successful transition of the respiratory system. It is essential for warmth and comfort but does not provide specific information about the respiratory system.
Choice B rationale:
Suctioning the mouth and nose with a bulb syringe to clear mucus is important to ensure the airways are clear and the newborn can breathe effectively. This action helps assess the airway patency and successful initiation of breathing.
Choice C rationale:
Observing the chest and abdomen is crucial to assess the respiratory effort and symmetry. Normal chest movements and equal rise and fall of the abdomen indicate a successful transition of the respiratory system.
Choice D rationale:
Counting the number of respirations per minute is essential to determine if the respiratory rate falls within the expected reference range (around 30-60 breaths per minute for a newborn) and if there are any irregularities.
Choice E rationale:
Observing the color of the mucous membranes is important as cyanosis (blue discoloration) may indicate inadequate oxygenation. Pink mucous membranes are a positive sign, indicating a successful transition of the respiratory system.
Correct Answer is C
Explanation
Choice A rationale:
Iron is crucial for the development of hemoglobin, which carries oxygen to all parts of the body, including the bones, but it does not directly facilitate bone growth.
Choice B rationale:
While newborns do metabolize iron, their iron stores are limited, and breast milk alone may not meet their iron needs.
Choice C rationale:
When educating a parent about the use of iron-fortified formula for their newborn, it is essential to convey that newborns have a limited store of iron, which begins to deplete around the age of 6 months.
Choice D rationale:
Iron facilitating eyesight development is not a relevant aspect to consider when discussing the use of iron-fortified formula for a newborn. While iron is essential for various physiological functions, it is not specifically linked to eyesight development.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.