Nokea
A 2-day-old breastfeeding baby born via normal spontaneous vaginal delivery has just been weighed in the newborn nursery. The nurse determines that the baby has lost 3.5% of the birth weight. Which of the following nursing actions is appropriate?
- A. Do nothing because this is a normal weight loss.
- B. Notify the neonatologist of the significant weight loss.
- C. Advise the mother to bottle feed the baby at the next feed.
- D. Assess the baby for hypoglycemia with a glucose monitor.
Correct Answer: A
Rationale: Weight loss up to 7-10% is considered normal in the first few days due to fluid loss; 3.5% does not warrant immediate intervention.
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A client, 1 day postpartum (PP), is being monitored carefully after a significant postpartum hemorrhage. Which of the following should the nurse report to the obstetrician?
- A. Urine output 200 mL for the past 8 hours.
- B. Weight decrease of 2 pounds since delivery.
- C. Drop in hematocrit of 2% since admission.
- D. Pulse rate of 68 beats per minute.
Correct Answer: A
Rationale: Reduced urine output indicates potential hypovolemia.
The nurse is going to assist the mother with the first breastfeeding experience. Which of the following actions should the nurse perform first?
- A. Compare mother's and baby's identification bracelets.
- B. Help the mother into a comfortable position.
- C. Teach the mother about a proper breast latch.
- D. Tickle the baby's lips with the mother's nipple.
Correct Answer: A
Rationale: Identity verification ensures correct pairing.
A 4-day-old breastfeeding neonate whose birth weight was 2,678 grams has lost 100 grams since the cesarean birth. Which of the following actions should the nurse take?
- A. Nothing because this is an acceptable weight loss.
- B. Advise the mother to supplement feedings with formula.
- C. Notify the neonatologist of the excessive weight loss.
- D. Give the baby dextrose water between breast feedings.
Correct Answer: A
Rationale: Weight loss within 5% is normal.
During which phase of maternal adjustment will the mother relinquish the baby of her fantasies and accept the real baby?
- A. Letting-go
- B. Taking-in
- C. Taking-on
- D. Taking-hold
Correct Answer: A
Rationale: The correct answer is A: Letting-go. During this phase, the mother transitions from idealized fantasies about her baby to accepting the reality of the infant. She lets go of unrealistic expectations and embraces the actual characteristics of her child. Choice B, Taking-in, refers to the mother focusing on her own needs post-birth. Choice C, Taking-on, involves the mother identifying with her new role. Choice D, Taking-hold, pertains to the mother forming a strong bond with the baby. However, none of these phases specifically address the process of relinquishing idealized fantasies and accepting the real baby like the Letting-go phase does.
The physician declares after delivering the placenta of a client during a cesarean section that it appears that the client has a placenta accreta. Which of the following maternal complications would be consistent with this diagnosis?
- A. Blood loss of 2,000 mL.
- B. Blood pressure of 160/110.
- C. Jaundiced skin color.
- D. Shortened prothrombin time.
Correct Answer: A
Rationale: Placenta accreta causes significant blood loss.