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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale
Bright red bleeding in the third trimester of a pregnancy with an Rh-negative mother is an obstetric emergency and warrants the highest priority. The immediate assessment of the fetal heart rate (FHR) and the mother's contraction pattern is crucial. The nurse must determine if the bleeding is caused by conditions such as placental abruption or placenta previa, both of which are life-threatening for the mother and the fetus.
Choice B rationale
While a sterile vaginal examination may eventually be necessary to diagnose the cause of bleeding, it is not the immediate priority. Assessment of fetal well-being and maternal status takes precedence. Additionally, performing a vaginal examination increases the risk of further hemorrhage and potential infection.
Choice C rationale
Leopold maneuvers are used to determine fetal presentation and position, but they are not the priority intervention in this scenario. The nurse's main concern is stabilizing the mother and assessing for signs of fetal distress.
Choice D rationale
Assessing the woman's Rh and Coombs status for RhoGam administration is important. Still, it is not the most immediate priority in this life-threatening situation. The priority is to assess fetal well-being and stabilize the mother. If placental abruption is suspected, RhoGam administration may not be indicated.
Correct Answer is D
Explanation
Choice A rationale
While monitoring the client’s vital signs is an important part of postpartum care, it would not directly address the issue of a boggy uterus that is displaced above and to the right of the umbilicus.
Choice B rationale
Notifying the healthcare provider is important, but it would not be the first action to take. The nurse should first attempt to address the issue.
Choice C rationale
Inspecting the perineal pad could provide information about the client’s postpartum bleeding, but it would not directly address the issue of a boggy uterus that is displaced above and to the right of the umbilicus.
Choice D rationale
Encouraging the client to void is the correct action. A full bladder can displace the uterus, preventing it from contracting properly. By emptying the bladder, the uterus may be able to contract and return to its normal position.
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