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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Related Questions
Correct Answer is C
Explanation
Choice A rationale
While shallow and irregular respirations can be a sign of respiratory distress in newborns, it is not the most indicative symptom. Newborns naturally have irregular breathing patterns, which can include periods of rapid breathing followed by periods of no breathing for up to 10 seconds.
Choice B rationale
A respiratory rate of 50 breaths per minute is within the normal range for a newborn. Newborns typically breathe at a rate of 40 to 60 breaths per minute.
Choice C rationale
Flaring of the nares, or nostrils, is a common sign of respiratory distress in newborns. It indicates that the baby is working hard to breathe.
Choice D rationale
Abdominal breathing with synchronous chest movement is normal in newborns. It is not a sign of respiratory distress.
Correct Answer is B
Explanation
Choice A rationale
While monitoring vital signs is important in a client with eclampsia, it should be done more frequently than every 4 hours due to the risk of seizures and other complications.
Choice B rationale
Keeping an airway at the bedside is crucial for a client with eclampsia. If a seizure occurs, the airway can be used to ensure the client’s airway remains open.
Choice C rationale
Liberal family visitation may not be appropriate for a client with eclampsia who needs a quiet and stress-free environment to prevent triggering seizures.
Choice D rationale
Assessing temperature every hour is not specifically related to the care of a client with eclampsia.
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