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
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Hemophilia is a genetic bleeding disorder in which the blood does not clot properly. It primarily affects the coagulation factors responsible for clot formation. In individuals with hemophilia, bleeding tends to occur most commonly in the joints, particularly in the large weight-bearing joints like the knees, elbows, and ankles. This is known as hemarthrosis and can lead to significant pain and joint damage.
While bleeding in other areas of the body can occur in hemophilia, such as the muscles or soft tissues, joint bleeding is one of the hallmark features of the condition.
The other options, B (intestines), C (brain), and D (pericardium), are less commonly associated with bleeding in hemophilia. Although bleeding can occur in various locations, joint bleeding is the most characteristic and commonly seen manifestation in individuals with hemophilia.
Correct Answer is C
Explanation
A. Neutropenic Precautions: Neutropenia refers to a low neutrophil count, a type of white blood cell responsible for fighting infections. While children with leukemia are at risk for neutropenia due to the disease and its treatment, the primary concern in this scenario is the critically low platelet count and the risk of bleeding. Neutropenic precautions focus on preventing infections.
B. Droplet Precautions: Droplet precautions are used when dealing with respiratory infections that are transmitted through respiratory droplets, such as coughing or sneezing. This is not the primary concern for a child with leukemia and a low platelet count, as the main risk is bleeding due to the low platelet count.
C. Bleeding Precautions: Leukemia, especially in a child with a critically low platelet count, puts the child at a high risk of bleeding. Platelets are essential for blood clotting, and when they are severely decreased, even minor injuries can lead to excessive bleeding. The nurse should take precautions to minimize the risk of bleeding. This includes avoiding invasive procedures, using a soft toothbrush, and ensuring that the child does not participate in activities that could result in injury.
D. Contact Precautions: Contact precautions are used to prevent the transmission of infectious diseases through direct contact. While a child with leukemia may have a weakened immune system and be at risk of infections, the primary concern in this case is the critically low platelet count and the risk of bleeding. Contact precautions are more relevant in cases of contagious diseases where physical contact could transmit the infection.
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