An infant, born yesterday and initially weighing 7.5 lbs (3,402 grams), weighs 7 lbs (3,175 grams) today. What action should the nurse take?
Encourage the mother to breastfeed more frequently.
Monitor the neonate’s stool and urine output for the last 24 hours.
Reassure the mother that this is a normal weight loss.
After verifying the weight’s accuracy, inform the healthcare provider.
The Correct Answer is C
Choice A rationale
While breastfeeding more frequently can be beneficial for the mother-infant bonding and milk production, it does not directly address the infant’s weight loss.
Choice B rationale
Monitoring the neonate’s stool and urine output for the last 24 hours can provide information about the infant’s hydration status. However, it does not directly address the concern of weight loss.
Choice C rationale
It is normal for newborns to lose some weight in the first few days after birth. This is often due to the loss of excess fluid. A weight loss of up to 10% of the birth weight is generally considered normal in the first week.
Choice D rationale
While it’s important to verify the accuracy of the weight measurement, informing the healthcare provider is not the immediate action required if the weight loss is within the normal range.
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Correct Answer is B
Explanation
Choice A rationale
While notifying the healthcare provider is important, it is not the first action to take. The nurse should first address the immediate issue of a potentially full bladder that could be displacing the uterus.
Choice B rationale
Encouraging the client to void can help if the bladder is full. A full bladder can displace the uterus and interfere with uterine contractions, leading to increased bleeding.
Choice C rationale
Administering ibuprofen can help with cramping, but it does not address the immediate issue of a potentially full bladder displacing the uterus.
Choice D rationale
Increasing the intravenous fluid rate is not the first action to take. The nurse should first address the immediate issue of a potentially full bladder displacing the uterus.
Correct Answer is B
Explanation
Choice A rationale
While acetaminophen can help reduce fever, it does not address the underlying cause of the client’s symptoms. Moreover, self-medication without proper medical advice can potentially harm the pregnancy.
Choice B rationale
The client’s symptoms of low-grade fever, moderate cramping, and heavy bright-red bleeding could indicate a serious condition such as a miscarriage or an ectopic pregnancy. Therefore, immediate medical evaluation is necessary.
Choice C rationale
While monitoring the flow of vaginal bleeding can provide useful information, it does not address the immediate need for medical evaluation given the client’s symptoms.
Choice D rationale
Resting at home might not be the best advice given the severity of the client’s symptoms. Immediate medical evaluation is necessary.
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