Which finding could prevent early discharge of a newborn who is now 12 hours old?
Voided, clear, pale urine three times since birth.
Birth weight of 3000 g.
Infant breastfed once with some difficulty latching on and sucking and once with some success for about 5 minutes on each breast.
One meconium stool since birth.
The Correct Answer is C
Choice A rationale
Voiding clear, pale urine three times in 12 hours is an appropriate sign of adequate fluid intake and renal function in a newborn. The normal range for voids in the first 24 hours is often at least one, and by day three, six to eight voids are expected. This output does not prevent early discharge as it suggests proper hydration and patent urinary tracts.
Choice B rationale
A birth weight of 3000 g is within the average range for a term newborn (typically 2500 to 4000 g). Weight alone, if within normal limits and stable, is not a factor that would delay discharge. Significant weight loss (over 10% of birth weight) or a weight below 2500 g is more concerning.
Choice C rationale
Significant difficulty with latching and sucking during two initial breastfeeding attempts could indicate problems with the infant's feeding readiness, coordination of suck-swallow-breathe reflex, or maternal technique. Establishing effective feeding is a key criterion for early discharge to ensure adequate caloric intake and prevent hypoglycemia or dehydration.
Choice D rationale
Passing one meconium stool within the first 12 hours of life is a normal and expected finding, indicating a patent anus and gastrointestinal tract function. Meconium passage typically occurs within the first 24 to 48 hours, and this finding is reassuring for discharge. —.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A rationale
While new parents need time to bond and establish their own family routines, a categorical statement telling grandparents to "leave you alone" is non-therapeutic and antagonistic. The nurse's role is to promote communication and identify resources, and grandparents can be significant sources of physical and emotional support, which is vital for maternal mental health and adjustment to parenthood.
Choice B rationale
A statement invoking the age or mortality of the grandparents uses emotional manipulation, which is inappropriate for a professional counseling relationship. This shifts the focus from the new parents' needs and the functional role of the grandparents to an appeal based on guilt or obligation, thus not providing an appropriate, objective explanation of their potential contribution.
Choice C rationale
Grandparents often possess a wealth of practical parenting knowledge and wisdom gained through experience, offering a positive resource for overwhelmed new parents. Furthermore, their involvement is crucial for the intergenerational transmission of cultural values and family history, helping the child develop a sense of identity and connection within the extended family structure.
Choice D rationale
While grandparent involvement can cause conflict if boundaries are not established, the blanket statement that it is "very disruptive" is judgmental and overgeneralized. The nurse should promote the potential benefits and then address potential conflicts by facilitating a conversation about establishing healthy boundaries and roles, which utilizes a more constructive and supportive approach.
Correct Answer is ["6"]
Explanation
Step 1 is: Assess the five components of the APGAR score at 5 minutes of life. Heart rate of 105 beats per minute (bpm) is ≥ 100 bpm, scoring 2 points. Respirations of 25 breaths per minute are ≤ 30, but the neonate is crying and breathing, scoring 1 point for slow/irregular/weak cry. Grimace with stimulation, which is a reflex irritability, scores 1 point. Flexed limbs with little movement, representing muscle tone, scores 1 point for some flexion of extremities. Pink color with bluish hands and feet (acrocyanosis) scores 1 point for pink body and blue extremities.
Step 2 is: Add the points for each component: 2 (Heart Rate) + 1 (Respiration) + 1 (Grimace) + 1 (Muscle Tone) + 1 (Color) = 6. Final calculated answer: 6.
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