A newborn who has not voided by 48 hours after birth should be ...

[nevelica]

A newborn who has not voided by 48 hours after birth should be assessed for which of the following? Note: Credit will be given only if all correct and no incorrect choices are selected. Select all that apply.
 
  1. Restlessness
  2. Pain
  3. Kidney distention
  4. Adequacy of fluid intake
  5. Lethargy

Question 2

The nurse has received an order to rupture a patient's membranes artificially. Which finding in the patient's history would lead the nurse to question the order?
 
  1. Group B strep negative yesterday
  2. HbsAg negative at 28 weeks
  3. HIV-positive X 3 years
  4. History of genital herpes

[epscape]

Answer to Question 1

1, 2, 4
Explanation: 1. A newborn who has not voided by 48 hours after birth should be assessed for restlessness.
2. A newborn who has not voided by 48 hours after birth should be assessed for pain.
4. A newborn who has not voided by 48 hours after birth should be assessed for adequacy of fluid intake.

Answer to Question 2

3
Rationale 1: Artificial rupture of the membranes increases the incidence of chorioamnionitis. Group B strep negative findings yesterday decrease the risk of infection. Artificial rupture of the membranes is appropriate for this patient.
Rationale 2: Artificial rupture of the membranes increases the incidence of perinatal transmission of hepatitis B. This patient is negative for hepatitis B; therefore, artificial rupture of the membranes is appropriate for this patient.
Rationale 3: Artificial rupture of the membranes increases the incidence of perinatal transmission of HIV, and should not be undertaken in HIV/AIDS-positive women.
Rationale 4: A history of genital herpes does not indicate that the patient is currently experiencing an outbreak. Artificial rupture of the membranes is appropriate for this patient.