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 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.
Correct Answer is C
Explanation
Option A is incorrect because Tanner staging is not solely based on developmental achievement according to age. It assesses physical development irrespective of age.
Option B is incorrect because it is not based on the color of pigmentation on the scrotum but rather on multiple physical characteristics.
Option C. Based on the development of pubic hair in girls.
The Tanner staging system, also known as sexual maturity rating or sexual maturity scale, is a system used to assess the sexual development of children and adolescents based on physical characteristics, primarily focusing on secondary sexual characteristics. It is used to assess the stage of puberty in both boys and girls. In the case of girls, it includes the development of pubic hair, breast development, and other changes like the growth of the areola.
Option D is incorrect because it doesn't solely focus on staged voice changes in males. The Tanner staging system includes a range of characteristics, including voice changes, genital development, and pubic hair growth, to assess sexual maturity in both males and females.
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