A primigravida client at 32-weeks gestation presents to the clinic with a report of a pounding headache. The client demonstrates hyperreflexia. The nurse should recognize the client's symptoms may be caused by which condition?

Rationale:

• Parents report infant can choke: Parents’ recognition of choking risk indicates they understood the teaching about feeding precautions and are observing the infant’s cues, which is a desired outcome of education.
• Infant refused bottle after 15 mL: Refusal to finish a bottle indicates ongoing feeding difficulties, suggesting interventions have not fully addressed the infant’s feeding challenges.
• Parents requested nurse feed infant: Reliance on the nurse to feed the infant shows parents are not yet fully confident or comfortable applying the feeding techniques independently, indicating partial effectiveness.
• Respirations 38 breaths/minute: Normalization of respiratory rate post-feeding reflects that the infant is tolerating feeding better and maintaining adequate oxygenation.
• Infant fell asleep after feeding: Falling asleep after such a small intake, especially after crying and refusing the bottle, suggests that the infant is fatigued and exhausted from the effort of feeding. This indicates that the feeding was not successful.
• Infant temperature 98.6° F (37.0° C): Reduction of fever indicates effective management of infection, supporting that interventions like acetaminophen and antibiotics are working.

Rationale:

A. Encourage the mother to increase frequency of breastfeeding: Encouraging more frequent feeds is important if weight loss exceeds the normal range or if feeding cues are not being met. In this case, the infant’s weight loss is within the expected 5–10% of birth weight during the first days of life.

B. Monitor the stool and urine output of the neonate for the last 24 hours: Monitoring elimination patterns helps assess hydration status and feeding effectiveness. However, since the weight loss is within the physiologic range, this step is not the most immediate action.

C. After verifying the accuracy of the weight, notify the healthcare provider: Notifying the provider is appropriate when weight loss is greater than 10% of birth weight or when the infant shows clinical signs of dehydration. In this case, the 6% loss is normal.

D. Inform and assure the mother that this is a normal weight loss: Normal neonatal physiology includes losing 5–10% of birth weight in the first 3–5 days due to fluid shifts, limited intake, and initial adaptation. The nurse should reassure the mother, explain that this is expected, and continue to encourage routine feeding and monitoring.