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
Unilateral lower leg pain is not a normal finding postpartum and could indicate a deep vein thrombosis, which requires immediate medical attention.
Choice B rationale
A soft, spongy fundus is not a normal finding postpartum. The uterus should be firm to prevent excessive bleeding.
Choice C rationale
A pulse rate of 56 beats/minute can be a normal finding postpartum. Pregnancy increases blood volume and cardiac output, and these changes can persist for some time after delivery.
Choice D rationale
Saturating two perineal pads per hour is not a normal finding postpartum and could indicate excessive bleeding.
Correct Answer is B
Explanation
Choice A rationale
Calcium is essential for the development of fetal bones and teeth, but it is not specifically linked to preventing neural tube defects like anencephaly.
Choice B rationale
Folic acid is vital for preventing neural tube defects, including anencephaly. It’s recommended for women of childbearing age and especially during the early stages of pregnancy.
Choice C rationale
Vitamin D is important for bone health, but its primary function is not directly related to preventing neural tube defects like anencephaly.
Choice D rationale
Iron is crucial for preventing anemia in pregnancy, supporting increased blood volume. However, it is not directly associated with preventing neural tube defects.
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