A mother is concerned about her 3-day-old breastfeeding newborn whose birth weight was 2678g and is now 2505g. What is the most appropriate response by the nurse?

Explain that this is an acceptable weight loss for this time.

Notify the healthcare provider of excessive weight loss.

Take the infant to the intensive care unit for an intravenous line.

Advise the mother to supplement each breastfeeding with formula.

Answer and Explanation

The Correct Answer is A

A. It is normal for newborns to lose up to 10% of their birth weight in the first few days. This weight loss is primarily due to fluid shifts and will resolve with regular breastfeeding.

B. Weight loss in this range is not excessive and does not require immediate intervention.

C. There is no indication for intensive care based on this weight loss alone.

D. Supplementing with formula is not necessary unless weight loss exceeds 10% or breastfeeding is inadequate.

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Correct Answer is C

Explanation

A. Providing iodine solution is a standard task, not advocacy.

B. Preparing equipment is part of procedural support, not advocacy.

C. Providing sucrose and non-nutritive sucking has been shown to reduce procedural pain in neonates, demonstrating advocacy for the infant’s comfort.

D. Restraining is necessary but does not directly advocate for comfort.

A. Entry of air into alveoli replacing the expelled amniotic fluid. B. Decreased oxygen levels after the cessation of placental blood flow. C. Upward movement of the diaphragm to create passive inspiration. D. Drying off and stimulating the newborn helps to trigger respiratory response.

Correct Answer is A

Explanation

A. The entry of air into the alveoli, replacing expelled amniotic fluid, is a critical mechanical stimulus that initiates the transition to neonatal breathing.
B. Decreased oxygen levels trigger chemical, not mechanical, stimuli.
C. The diaphragm moves downward during inspiration, not upward.
D. Drying and stimulation help initiate breathing through sensory stimulation, not mechanical.

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A mother is concerned about her 3-day-old breastfeeding newborn whose birth weight was 2678g and is now 2505g. What is the most appropriate response by the nurse?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is assisting a healthcare provider during an infant's circumcision. Which action by the nurse demonstrates the nurse is acting as the infant's client care advocate?

Correct Answer is C

Explanation

The nurse recognizes mechanical stimuli involved with the transition to extrauterine pulmonary function includes:

Correct Answer is A

Explanation

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