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 D
Explanation
A. This is not a primary consideration before bathing a newborn. The timing of the last feeding is more relevant to assessing the risk of hypoglycemia rather than determining readiness for a bath.
B. This temperature is slightly below the recommended range for newborns (36.5°C to 37.5°C). Bathing should be delayed until the newborn's temperature is stable.
C. While care of the umbilical cord is important, it does not determine the timing of the first bath. The cord can be kept dry even if the baby is bathed.
D. Ensuring that the newborn has maintained a stable body temperature for at least 2 hours is crucial before giving the first bath. Bathing can cause a drop in body temperature, so it's essential that the newborn's thermoregulation is stable to avoid hypothermia.
Correct Answer is A
Explanation
A blood glucose fingerstick of 40 mg/dL for an infant who is 1- hour old.
Choice A rationale:
This finding should be notified to the charge nurse immediately because a blood glucose level of 40 mg/dL in a 1-hour-old infant is significantly lower than the normal range. Hypoglycemia in newborns can lead to serious complications, including neurological issues. Normal blood glucose levels in newborns are typically around 45-90 mg/dL.
Choice B rationale:
A hematocrit of 60% in an 8-hour-old infant may be considered relatively high, but this is a normal finding in newborns. Hematocrit levels can be higher in neonates due to their unique physiological adaptation to extrauterine life.
Choice C rationale:
Jaundice in a 4-hour-old infant is a common occurrence and is not typically a cause for immediate concern. Physiological jaundice often appears after 24 hours of birth and resolves on its own.
Choice D rationale:
Acrocyanosis, bluish discoloration of the hands and feet, is a normal finding in newborns and is not considered a cause for concern. It occurs due to the immature peripheral circulation and typically resolves within a few days.
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