The new mother of a 2-day-old neonate who weighed 8 pounds at birth is distressed that the baby has lost one-half pound. The home health nurse's response is one of:

Alertness as such weight loss is not expected

Reassurance as this is a normal weight loss

Alarm as this is a drastic weight loss

Concern as this may be an indicator of inadequate nutrition

Answer and Explanation

The Correct Answer is B

A. Alertness as such weight loss is not expected: This response may unnecessarily alarm the mother when, in fact, some weight loss in the early days is normal.

B. Reassurance as this is a normal weight loss.

It is normal for newborns to lose some weight during the first few days of life. The loss is often related to fluid loss, changes in feeding patterns, and initial adjustment to life outside the womb. A loss of one-half pound in a 2-day-old neonate is generally considered within the normal range. It's important for the nurse to reassure the new mother that this weight loss is expected and not a cause for alarm. Newborns typically start to regain their birth weight within a week or two. This reassurance can help ease the mother's distress and anxiety.

C. Alarm as this is a drastic weight loss: Characterizing this weight loss as "drastic" is not accurate or helpful and would likely increase the mother's anxiety.

D. Concern as this may be an indicator of inadequate nutrition: Jumping to the conclusion of inadequate nutrition without further assessment and evidence is premature and may unnecessarily worry the mother. It's important to start with reassurance and then investigate if there are concerns about nutrition.

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Correct Answer is C

Explanation

Option A (Place the infant in reverse Trendelenburg position) and option B (Place the infant in the knee to chest position) are not the immediate actions to address this situation. While these positions might be used in specific situations, assessing blood pressure is more appropriate in this context to evaluate for potential vascular issues.

Option C. Take the infant's blood pressure in all extremities.

In an infant with weaker femoral pulses compared to the brachial and radial pulses, there might be a concern about coarctation of the aorta (a narrowing of the aorta), which can affect blood flow to the lower extremities. To confirm this and assess for potential issues, taking blood pressure measurements in all four extremities is crucial. This comparison can help identify pressure differentials between the upper and lower extremities, which is a hallmark sign of coarctation of the aorta.

Option D (Notify the Physician) is generally a good step, but taking the blood pressure in all extremities should be done first to provide comprehensive information for the physician when discussing the infant's condition.

A. Obtain a throat culture. B. Visualize the epiglottis with a tongue depressor C. Place the child in an upright position D. Transport the child to radiology for a throat x-ray

Correct Answer is C

Explanation

A. Obtaining a throat culture and B. visualizing the epiglottis with a tongue depressor are not safe actions for the nurse to perform without appropriate medical equipment and expertise. These actions can trigger a sudden airway obstruction in a child with epiglottitis. The priority is to ensure airway patency and seek immediate medical assistance.

C. Place the child in an upright position.

Suspected epiglottitis is a medical emergency that can result in rapid airway obstruction. Placing the child in an upright position helps improve airflow by allowing the throat to open and reduces the risk of complete airway obstruction. It's important not to perform invasive procedures (such as throat culture or visualization of the epiglottis) without proper medical equipment and expertise, as these actions can lead to worsening airway obstruction.

D. Transporting the child to radiology for a throat x-ray is not appropriate in this situation, as it may delay necessary interventions to secure the airway.

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The new mother of a 2-day-old neonate who weighed 8 pounds at birth is distressed that the baby has lost one-half pound. The home health nurse's response is one of:

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Naxlex Comprehensive Predictor Exams

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Explanation

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Explanation

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