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. Elevated hemoglobin and bilirubin. B. Acrocyanosis and unstable thermoregulation. C. Generalized mottling and uncoordinated suck. D. Lethargy and pallor.

Correct Answer is D

Explanation

A. Elevated hemoglobin and bilirubin: These findings are more consistent with jaundice or polycythemia, not sepsis.
B. Acrocyanosis and unstable thermoregulation: Acrocyanosis is normal in newborns; thermoregulation issues are concerning but nonspecific for sepsis.
C. Generalized mottling and uncoordinated suck: These may occur in sepsis but are less specific compared to lethargy and pallor.
D. Lethargy and pallor: These are classic signs of neonatal sepsis, a potentially life-threatening condition requiring immediate intervention.

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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

A 1-day old newborn was born to a mother who had positive vaginal cultures for Group Beta Strep. The mother was only in labor for 1 hour prior to birth. What findings would indicate possible neonatal sepsis?

Correct Answer is D

Explanation

The nurse is reinforcing education about circumcision care. Which statement by the parents demonstrates an understanding?

A nurse is completing a home visit to a mother who is 3 days postpartum and breastfeeding her newborn. The mother expresses concern about the amount of weight the newborn has lost since birth. Which of the following is a response the nurse should make?

A nurse is reinforcing teaching about newborn care with a postpartum client. Which of the following statements by the client indicates a need for further teaching?

A newborn is experiencing symptoms of cold stress. Which assessment data by the nurse will require further evaluation for stress protocol? (Select All that Apply.)

The nurse is caring for a 1-day postpartum client that is breastfeeding a healthy full-term newborn. The client requests a bottle of formula and verbalizes that she does "not have any milk". What is the most appropriate response?

The nurse is caring for a 26-week-gestation infant diagnosed with periventricular hemorrhage and currently intubated. What is the most appropriate nursing action(s) for this infant?

The nurse is instructing a new parent on appropriate circumcision care. Which statement by the parent demonstrates effective teaching?