Which action should the nurse take if an infant, who was born yesterday weighing 7.5 lbs. (3,402 grams), weighs 7 lbs (3,175 grams) today?
Monitor the stool and urine output of the neonate for the last 24 hours.
Inform and assure the mother that this is a normal weight loss.
After verifying the accuracy of the weight, notify the healthcare provider.
Encourage the mother to increase frequency of breastfeeding.
The Correct Answer is B
Rationale:
A. Monitor the stool and urine output of the neonate for the last 24 hours: Monitoring elimination patterns is important to assess hydration and feeding adequacy. However, a weight loss of approximately 6% from birth is within the expected physiologic range and does not require immediate intervention.
B. Inform and assure the mother that this is a normal weight loss: Newborns typically lose 5–10% of their birth weight during the first 3–5 days due to fluid shifts and limited initial intake. The nurse’s priority is to reassure the mother, explain that this is expected, and continue supporting regular feeding.
C. After verifying the accuracy of the weight, notify the healthcare provider: Notifying the healthcare provider is necessary if the weight loss exceeds 10% of birth weight or if there are signs of dehydration. In this case, the loss is within the normal range.
D. Encourage the mother to increase frequency of breastfeeding: Increasing feeding frequency is important if the infant shows inadequate intake or excessive weight loss. Since the weight loss is physiologic and expected, routine feeding patterns can continue.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["10"]
Explanation
Calculation:
Desired dose = 500 mg.
Available concentration = 250 mg / 5 mL
= 50 mg/mL.
- Calculate the volume to administer in milliliters (mL).
Volume to administer (mL) = Desired dose (mg) / Available concentration (mg/mL)
= 500 mg / 50 mg/mL
= 10 mL.
Correct Answer is C
Explanation
Rationale:
A. Shallow and irregular respirations: Shallow and irregular respirations are often normal in newborns, especially during sleep or periods of rest. These patterns alone do not indicate respiratory distress unless accompanied by other signs such as retractions or cyanosis.
B. Abdominal breathing with synchronous chest movement: Normal newborns primarily use diaphragmatic (abdominal) breathing with coordinated chest movement. This is expected and does not signify respiratory distress.
C. Flaring of the nares: Flaring of the nares occurs when the newborn is attempting to increase airflow due to difficulty breathing. It is a classic early sign of respiratory distress and indicates that the infant is using accessory muscles to breathe, requiring prompt evaluation.
D. Respiratory rate of 50 breaths/minute: A respiratory rate of 50 breaths per minute is within the normal newborn range of 30–60 breaths per minute. While it should be monitored, this rate alone does not indicate respiratory distress.
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