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
Explanation
A. This condition typically results from excessive loss of acid, often due to vomiting or diuretics. It is not the most likely concern in a cold environment with an infant who has been crying and kicking.
B. A cold environment can lead to nonshivering thermogenesis in newborns, where they metabolize brown fat to generate heat. This process can lead to increased lactic acid production, potentially causing metabolic acidosis. The infant's fatigue following crying and kicking may indicate that the body has expended significant energy to stay warm, making metabolic acidosis a priority concern.
C. While hunger could be a reason for crying, it is not the priority concern in this scenario where environmental cold and fatigue are present.
D. Overstimulation might cause crying, but the environmental cold and subsequent risk of metabolic acidosis are more critical concerns in this context.
Correct Answer is D
Explanation
Choice A rationale:
15 mL is not the correct choice because it only considers the first two feedings and does not account for the intake during the entire shift.
Choice B rationale:
30 mL is not the correct choice because it only considers the first three feedings and does not account for the intake during the entire shift.
Choice C rationale:
45 mL is not the correct choice because it only considers the first four feedings and does not account for the intake during the entire shift.
Choice D rationale:
The nurse should record 60 mL of formula as the newborn's intake for the shift. To calculate the total intake, you add the amounts from each feeding: 0.5 oz + 1 oz + 0.5 oz + 0.5 oz + 0.5 oz = 60 mL. Remember that 1 fluid ounce (oz) is approximately equal to 30 mL.
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