Nokea
The nurse is assessing a 3-day-old, breastfed newborn who weighed 7 pounds, 8 ounces at birth. The newborn's mother is now concerned that the newborn weighs 6 pounds, 15 ounces. Which is the most appropriate nursing intervention?
- A. Recommend supplemental feedings of formula.
- B. Explain that this weight loss is within normal limits.
- C. Assess child further to determine cause of excessive weight loss.
- D. Encourage mother to express breast milk for bottle feeding the newborn.
Correct Answer: B
Rationale: It is normal for newborns to lose weight in the first few days of life, typically up to 10% of their birth weight. In this case, the newborn's weight loss from 7 pounds, 8 ounces to 6 pounds, 15 ounces is within the expected range. It is important for the nurse to reassure the mother that this weight loss is normal and to encourage continued breastfeeding on demand to support newborn hydration and nutrition. There is no need for supplemental feedings at this point unless there are other signs of feeding issues or concerns.
You may also like to solve these questions
Place in order the expected sequence of fine motor developmental milestones for an infant beginning with the first milestone achieved and ending with the last milestone achieved. Provide answer using lowercase letters separated by commas (e.g., a, b, c, d, e).
- A. Voluntary palmar grasp
- B. Reflex palmar grasp
- C. Puts objects into a container
- D. Neat pincer grasp
Correct Answer: B
Rationale: 1. Reflex palmar grasp (B) - Infants are born with a reflex called the palmar grasp reflex, which means they automatically close their fingers around an object placed in their palm. This reflex typically disappears around 3-4 months of age.
Which of the ff is an assessment finding in a client with bonchiectasis?
- A. Same amount of sputum at all stages of the disease
- B. Non productive cough
- C. Expectoration of small amounts of sputum
- D. Worsening cough with position changes
Correct Answer: C
Rationale: Bronchiectasis is a condition characterized by the abnormal widening and thickening of the bronchial tubes, leading to a build-up of mucus. One of the common assessment findings in clients with bronchiectasis is the expectoration of small amounts of sputum. This is due to the increased mucus production and impaired clearance from the airways. The sputum may be foul-smelling and may contain pus or blood due to chronic infection and inflammation in the bronchial tubes.
The nurse is caring for a 3-week-old preterm newborn born at 29 weeks of gestation. While taking vital signs and changing the newborn's diaper, the nurse observes the newborn's color is pink but slightly mottled, arms and legs are limp and extended, hiccups are present, and heart rate is regular and rapid. The nurse should recognize these behaviors as manifestations of:
- A. stress.
- B. subtle seizures.
- C. preterm behavior.
- D. onset of respiratory distress.
Correct Answer: C
Rationale: The behaviors described, such as slightly mottled skin, limp and extended extremities, hiccups, and a rapid but regular heart rate, are typical of preterm newborn behavior. Preterm infants often exhibit these characteristics due to their immature neurological and physiological systems. The mottled skin may be due to the immature vascular system, while the limp and extended extremities are common in preterm newborns as they have less muscle tone compared to full-term infants. Hiccups are also common in newborns, including preterm infants, and are generally not a cause for concern. The rapid heart rate is typical in newborns, particularly in the immediate postnatal period. Therefore, in this scenario, these behaviors are most likely related to the preterm status of the newborn rather than indicating stress, seizures, or respiratory distress.
A neonate, who was delivered by Cesarean section for a breech presentation, is being examined in the neonatal nursery. For which of the following complications should the nurse carefully assess the baby?
- A. Developmental dysplasia of the hips (DDH)
- B. Legg-Calve-Perthes (LCP)
- C. Duchenne muscular dystrophy (DMD)
- D. Slipped capital femoral epiphysis (SCFE)
Correct Answer: A
Rationale: A neonate delivered by Cesarean section for a breech presentation is at higher risk for developmental dysplasia of the hips (DDH). Breech presentation, especially frank breech, increases the chance of hip instability and DDH due to the positioning of the legs in utero. DDH is a condition where the ball and socket joint of the hip does not properly form, leading to potential dislocation of the hip joint. It is important for the nurse to carefully assess the neonate for signs of hip dysplasia, such as limited hip abduction or asymmetry in the thigh folds, to facilitate early detection and intervention for optimal outcomes. Legg-Calve-Perthes (LCP), Duchenne muscular dystrophy (DMD), and slipped capital femoral epiphysis (SCFE) are not specifically related to breech delivery, and therefore, are less likely to be
A 3-year-old female is hospitalized for a femur fracture. As her nurse, what nursing action would help foster the child's sense of autonomy?
- A. Allow the child to choose what time to take her oral antibiotics.
- B. Allow the child to have a doll for medical play.
- C. Allow the child to administer her own dose of Keflex (cephalexin) via oral syringe.
- D. Allow the child to watch age-appropriate videos.
Correct Answer: B
Rationale: Allowing preschoolers to participate in actions for which they are capable is an excellent way to enhance their sense of autonomy.