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Newborn, 2 days old, lost 6 ounces since birth
A mother is upset because her newborn has lost 6 ounces since birth 2 days ago. The nurse informs the mother that it is normal for a newborn to lose which percentage of their birth weight within the first week of life?
- A. 10% to 15% of their birth weight.
- B. 20% of their birth weight.
- C. 15% to 18% of their birth weight.
- D. 5% to 10% of their birth weight.
Correct Answer: D
Rationale: 5% to 10% of their birth weight is correct because this range is within the normal limits for a newborn weight loss. Newborns lose some weight due to insufficient caloric intake, fluid loss, and metabolic adjustments in the first week after birth.
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Infant with axillary temperature of 35.9C (96.6F)
An infant's axillary temperature is 35.9C (96.6F). The priority nursing action is to:
- A. chart the normal axillary temperature.
- B. recheck the infant's temperature rectally.
- C. place the infant in a radiant warmer.
- D. have the mother breastfeed the infant.
Correct Answer: C
Rationale: The low temperature indicates hypothermia, and placing the infant in a radiant warmer is the priority to stabilize body temperature and prevent complications.
Client after amniotomy
After an amniotomy, which action by the nurse takes priority?
- A. Change the patient's gown.
- B. Assess the fetal heart rate.
- C. Estimate the amount of amniotic fluid.
- D. Assess the color of the amniotic fluid.
Correct Answer: B
Rationale: Assessing the fetal heart rate is the priority after an amniotomy to ensure the fetus tolerates the procedure and detect any distress.
WIC program
The Women, Infants, and Children (WIC) program provides
- A. immunizations for high-risk infants and children.
- B. screening for infants with developmental disorders.
- C. supplemental food supplies to low-income pregnant or breastfeeding women.
- D. well-child examinations for infants and children living at the poverty level.
Correct Answer: C
Rationale: WIC provides supplemental food supplies to low-income pregnant or breastfeeding women and children up to age 5 at nutritional risk.
Client receiving oxytocin (Pitocin) infusion
The priority nursing care associated with an oxytocin (Pitocin) infusion is:
- A. Measuring urinary output.
- B. Evaluating cervical dilation.
- C. Increasing infusion rate every 30 minutes.
- D. Monitoring uterine response.
Correct Answer: D
Rationale: Monitoring uterine response is critical as oxytocin can cause excessive contractions, risking fetal distress, uterine rupture, or placental abruption.
Client 2 hours postpartum, vaginal birth
A nurse is caring for a client who is 2 hours postpartum following a vaginal birth. Which of the following findings indicates the client's bladder is distended?
- A. Client report of frequent uterine contractions.
- B. Fundus palpable to right of midline.
- C. Less than 2.5 cm of rubra lochia on perineal pad.
- D. Client report of increased thirst.
Correct Answer: B
Rationale: A fundus palpable to the right of midline suggests a distended bladder, which can displace the uterus from its normal position.