A nurse is completing a home visit to a mother who is 3 days postpartum and breastfeeding her newborn. The mother expresses concern about the amount of weight the newborn has lost since birth. Which of the following is a response the nurse should make?

“The cause might be too short or infrequent feedings.”

“It is due to the newborn’s loss of the influence of the maternal hormones.”

“This might be related to your baby having 3 stools a day.”

“You might want to offer water supplements between feedings.”

Answer and Explanation

The Correct Answer is A

Choice A reason:

“The cause might be too short or infrequent feedings.”: Newborns typically lose weight in the first few days after birth, which is normal. However, if the weight loss is significant, it could be due to inadequate feeding. Breastfed newborns should be fed 8-12 times in 24 hours to ensure they are getting enough milk. Short or infrequent feedings can lead to insufficient intake, resulting in weight loss2. Ensuring proper latch and feeding techniques can help address this issue.

Choice B reason:

“It is due to the newborn’s loss of the influence of the maternal hormones.”: While maternal hormones do influence the newborn, their loss is not a primary cause of significant weight loss. The initial weight loss is more related to fluid loss and the transition to breastfeeding.

Choice C reason:

“This might be related to your baby having 3 stools a day.”: Frequent stools are common in newborns, especially those who are breastfed. While it can contribute to weight loss, it is usually not the main cause of significant weight loss. Monitoring the baby’s feeding and ensuring they are getting enough milk is more critical.

Choice D reason:

“You might want to offer water supplements between feedings.”: Offering water supplements to a newborn is not recommended, especially for breastfed babies. Breast milk provides all the necessary hydration and nutrients. Introducing water can interfere with breastfeeding and reduce the baby’s intake of breast milk, potentially leading to further weight loss.

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Correct Answer is D

Explanation

Choice A Reason:

Using the intercostal space as a landmark for measuring chest circumference is not standard practice. The intercostal spaces are the spaces between the ribs, and using them as a reference point can lead to inconsistent measurements due to variations in rib spacing and positioning.

Choice B Reason:

The xiphoid process is the lower part of the sternum. While it is a significant anatomical landmark, it is not used for measuring chest circumference in newborns. The xiphoid process is located too low on the chest to provide an accurate and consistent measurement of chest circumference.

Choice C Reason:

The sternal notch, also known as the jugular notch, is the upper part of the sternum. Similar to the xiphoid process, it is not used for measuring chest circumference in newborns. The sternal notch is located too high on the chest and does not provide a consistent reference point for chest circumference measurements.

Choice D Reason:

The nipple line is the correct anatomical landmark for measuring the chest circumference of a newborn. This method ensures that the measurement is taken at a consistent and reproducible location across different individuals, providing an accurate assessment of the chest size relative to growth and development standards.

A. Increase in lochia. B. Report of absent breast pain. C. Increase in blood pressure. D. Fundus firm to palpation.

Correct Answer is D

Explanation

Choice A Reason:

An increase in lochia is not an indicator of methylergonovine’s effectiveness. Methylergonovine is used to prevent or treat postpartum hemorrhage by causing the uterus to contract. An increase in lochia could indicate ongoing bleeding, which would suggest that the medication is not working effectively.

Choice B Reason:

A report of absent breast pain is unrelated to the effectiveness of methylergonovine. This medication specifically targets uterine contractions to control bleeding and does not have a direct effect on breast pain.

Choice C Reason:

An increase in blood pressure can be a side effect of methylergonovine, but it is not an indicator of its effectiveness in controlling postpartum hemorrhage. The primary goal of the medication is to ensure the uterus contracts properly to prevent excessive bleeding.

Choice D Reason:

A fundus that is firm to palpation indicates that the uterus is contracting effectively, which is the desired outcome of administering methylergonovine. This finding suggests that the medication is working to control postpartum hemorrhage by promoting uterine contractions.

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A nurse is completing a home visit to a mother who is 3 days postpartum and breastfeeding her newborn. The mother expresses concern about the amount of weight the newborn has lost since birth. Which of the following is a response the nurse should make?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is completing the admission assessment of a newborn. Which of the following anatomical landmarks should the nurse use when measuring the newborn’s chest circumference?

Correct Answer is D

Explanation

A nurse is caring for a client who is postpartum and received methylergonovine. Which of the following findings indicates that the medication was effective?

Correct Answer is D

Explanation

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