A nurse is caring for a new mother who is breastfeeding her term newborn. The newborn weighed 3.4 kg (7.5 lb) at birth and weighed 3.3 kg (7.3 lb) on the second day of life. The mother expresses concern about the weight loss and asks the nurse about the amount of her breast milk. Which of the following responses by the nurse is appropriate?
"A healthy newborn can lose 6% of his birth weight before starting to gain weight."
"Why don't you switch to formula to make sure your baby is eating enough?"
"It is common for new mothers to worry that they are not making enough milk for their baby."
"Your newborn will need to remain in the hospital so his weight can be monitored."
The Correct Answer is A
Choice A rationale: Weight loss in the first few days after birth is normal for newborns, and a weight loss of up to 7-10% of the birth weight is considered within the expected range. A 6% weight loss is within normal limits, and it is reassuring to inform the mother that this is typical.
Choice B rationale: Suggesting switching to formula is not necessary based on the weight loss described. Breastfeeding provides adequate nutrition for most newborns, and early weight loss is typical and not a cause for alarm.
Choice C rationale: While it is true that new mothers may worry about breastfeeding and milk supply, this response does not address the specific weight loss concern and might not fully reassure the mother.
Choice D rationale: A 6% weight loss is within the expected range for a newborn and does not warrant hospitalization. It is a normal finding, and most newborns will start to regain their birth weight within a few days of life.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
The correct answer is Choice D: Contraction lasting 85 seconds.
Choice A rationale: A contraction resting period of 35 seconds is normal and expected during labor. The resting period allows the uterine muscle to relax and replenish its oxygen supply, which is essential for fetal well-being. The resting period also gives the client a chance to rest and cope with the pain of labor. A normal resting period ranges from 30 to 90 seconds, depending on the stage and phase of labor¹².
Choice B rationale: A heart rate of 100/min for a 10-min period is within the normal range for an adult. The normal resting heart rate for an adult is 60 to 100 beats per minute (bpm)³. During labor, the heart rate may increase due to factors such as pain, anxiety, dehydration, fever, or infection. However, a heart rate of 100/min is not considered a sign of distress or complication, unless it is accompanied by other symptoms such as chest pain, shortness of breath, or palpitations⁴⁵.
Choice C rationale: Four contractions in a 10-min period is a normal frequency for labor contractions. The frequency of contractions refers to how often they occur, measured from the beginning of one contraction to the beginning of the next. The normal frequency of contractions varies depending on the stage and phase of labor, but generally ranges from two to five contractions in 10 minutes¹².
Choice D rationale: A contraction lasting 85 seconds is too long and should be reported to the provider. The duration of contractions refers to how long they last, measured from the beginning to the end of one contraction. The normal duration of contractions ranges from 30 to 70 seconds, depending on the stage and phase of labor¹². A contraction lasting longer than 90 seconds is considered a prolonged contraction, which can reduce the blood flow and oxygen supply to the placenta and the fetus, leading to fetal hypoxia and acidosis. Prolonged contractions can also cause uterine rupture, placental abruption, or maternal hemorrhage .
Correct Answer is ["B","C","E"]
Explanation
Choice A rationale: Keeping the newborn in the center of a large crib is not a specific calming strategy and may not offer the comfort and security that the baby needs.
Choice B rationale: Taking the newborn for a ride in the car can be a calming strategy for some babies. The gentle motion and humming sound of the car can help soothe the baby.
Choice C rationale: Carrying the newborn in a front or backpack can provide comfort and security to the baby. The closeness to the parent's body and the rhythmic movement can help calm the baby.
Choice D rationale: Allowing the newborn to continue crying until she falls asleep is not a recommended strategy. Responding to the baby's cries and providing comfort and soothing is essential for the baby's emotional well-being.
Choice E rationale: Swaddling the newborn in a receiving blanket can help mimic the feeling of being in the womb, providing comfort and security to the baby. It can also prevent the startle reflex and promote better sleep.
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