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 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.
Correct Answer is D
Explanation
A. Back to sleep: While placing babies on their backs to sleep is essential for reducing the risk of sudden infant death syndrome (SIDS), it does not prevent flat spots. Instead, tummy time while the baby is awake helps balance the time spent on their back.
B. Take the baby for walks: Taking a baby for walks is beneficial for overall development and stimulation but does not directly prevent flat spots on the head.
C. Keep them awake most of the day: This is not a safe or recommended practice. Babies need sufficient sleep for proper growth and development.
D. Tummy time helps prevent flat spots by reducing the amount of time the baby spends lying on their back. It also strengthens neck, shoulder, and arm muscles, encouraging the baby to move their head more freely and develop motor skills.
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