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
Choice A rationale:
Going to the emergency room for black stools without abdominal pain or cramping is not warranted in this situation.
Choice B rationale:
Having the client come to the office to check things out may not be necessary since black stools can be an expected side effect of iron supplements and do not necessarily indicate a problem.
Choice C rationale:
Asking about the client's diet is a valid question, but the black stools are likely due to iron supplements' effects and not related to dietary choices.
Choice D rationale:
Black stools are a known side effect of iron supplements. When iron is broken down during digestion, it can cause the stools to appear black or dark. As the client has no other concerning symptoms like abdominal pain or cramping, this response by the nurse reassures the client that the finding is expected and not a cause for alarm.
Correct Answer is B
Explanation
Choice A rationale:
Encouraging the client to nurse more frequently will help with milk production and breastfeeding but is not the priority action based on the data provided.
Choice B rationale:
A temperature elevation above 38°C (100.4°F) in the postpartum period can indicate infection. The nurse should report this finding to the healthcare provider for further evaluation and management.
Choice C rationale:
Increasing IV fluids is not indicated based on the data provided. The client's vital signs are within the expected range for the postpartum period.
Choice D rationale:
Emptying the bladder can be important to prevent bladder distention and discomfort, but it is not the priority action based on the data provided.
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