Which diagnosis is most appropriate for a newborn who has not voided within 24 hours after delivery?

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Nursing Care of the Newborn Quizlet Questions

Question 1 of 5

Which diagnosis is most appropriate for a newborn who has not voided within 24 hours after delivery?

Correct Answer: A

Rationale: The correct answer is A: Hypovolemia related to insufficient fluid intake. In a newborn, the inability to void within 24 hours after birth can indicate dehydration and hypovolemia due to insufficient fluid intake. Newborns need to pass urine within the first 24 hours of life to show adequate hydration. Altered growth and development (choice B) is not relevant to the immediate concern of no voiding. Altered nutrition (choice C) is unlikely to cause the absence of urine output. Constipation (choice D) is less likely in a newborn and is not the primary concern when a newborn fails to void.

Question 2 of 5

A mother asks the newborn nursery RN why her newborn's eyes are yellow. Which offers the mother the most accurate explanation?

Correct Answer: C

Rationale: The correct answer is C because jaundice in newborns is often due to increased bilirubin levels. Bilirubin is a byproduct of the breakdown of red blood cells and can cause yellowing of the skin and eyes. The RN suggests laboratory work to confirm the diagnosis and determine the severity. Choice A is incorrect as kernicterus is a serious condition resulting from untreated severe jaundice, not a likely immediate concern without confirming the diagnosis first. Choice B is incorrect because while a newborn's liver is indeed immature, jaundice still needs to be monitored and managed appropriately. Choice D is incorrect as prematurity does increase the risk of jaundice, but it doesn't explain why the baby's eyes are yellow.

Question 3 of 5

Which baby is at highest risk of skin infection upon discharge?

Correct Answer: B

Rationale: The correct answer is B, a newborn with a new circumcision, as this procedure involves an incision, making the baby more susceptible to skin infections. Circumcision wounds need proper care to prevent infection. Choice A is incorrect because scabs forming over heels where blood has been drawn do not necessarily indicate a higher risk of skin infection. Choice C, a newborn with jaundice, is incorrect as jaundice affects the liver and does not directly increase the risk of skin infection. Choice D, a newborn with milia, is incorrect because milia are harmless and do not increase the risk of skin infection.

Question 4 of 5

Upon discharge, parents of a newborn reveal their plans to take their newborn to the beach with them on a vacation when the newborn is 3 months old. Which statement by the nurse is the most appropriate?

Correct Answer: D

Rationale: The correct answer is D because newborns have delicate skin that is highly susceptible to sunburn and heat-related issues. Placing the newborn in lightweight clothing and in the shade helps protect their sensitive skin from harmful UV rays. This approach minimizes the risk of sunburn and overheating. A is incorrect because newborns should not be exposed to direct sunlight for prolonged periods. B is inappropriate as it is important for newborns to be with their parents for bonding and care. C is incorrect as sunscreen is not recommended for infants under 6 months of age due to potential skin irritation and absorption concerns.

Question 5 of 5

Which newborn reflex is elicited by stroking the lateral sole of the infant's foot from the heel to the ball of the foot?

Correct Answer: A

Rationale: The correct answer is A: Babinski reflex. This reflex is elicited by stroking the lateral sole of the infant's foot, causing the big toe to extend and the other toes to fan out. This response is normal in infants up to 2 years old. The other choices are incorrect because: B: Stepping reflex is the automatic movement of the legs when held upright with the feet touching a surface. C: Tonic neck reflex occurs when an infant turns their head to one side, the arm on that side extends while the opposite arm flexes. D: Plantar grasp reflex is when pressure is applied to the sole of the foot, causing the toes to curl.

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