A nurse conducts an infant assessment on the second day after birth. A physical assessment of the newborn reveals the infant has dry lips and a dry oral cavity and has had only one wet diaper rather than the expected two

Question

What is the primary nursing diagnosis for this infant?
1. Risk for Imbalanced Nutrition: Less than body requirements related to mother's increased caloric need
2. Ineffective breastfeeding related to mother's lack of knowledge about breastfeeding techniques
3. Risk for infection related to impaired skin integrity
4. Imbalanced Nutrition: Less than body requirements related to dehydration as evidenced by dry mucus membranes and decreased urine output

Answer 1

Correct Answer: 4
Rationale 1: The infant has progressed beyond a risk diagnosis as evidenced by the signs of dehydration. Instead, this infant should receive the actual diagnosis of imbalanced nutrition.
Rationale 2: Although dehydration is often caused by ineffective breastfeeding, there is no evidence that this is related to the mother's lack of knowledge about breastfeeding techniques. A maternal assessment would be needed to make this diagnosis.
Rationale 3: Dry lips and mouth may lead to impaired skin integrity, but this is not the primary nursing diagnosis that needs immediate intervention.
Rationale 4: The infant is displaying signs of dehydration, which most often occurs when the infant is not receiving enough fluids through breastfeeding or bottle-feeding. Newborns require 140-160 ml/kg/day of fluids to prevent dehydration because the newborn has a decreased ability to concentrate urine and their overall metabolic rate is high.