The new mother of a 2-day-old neonate who weighed 8 pounds at birth is distressed that the baby has lost one-half pound. The home health nurse's response is one of:

Alertness as such weight loss is not expected

Reassurance as this is a normal weight loss

Alarm as this is a drastic weight loss

Concern as this may be an indicator of inadequate nutrition

Answer and Explanation

The Correct Answer is B

A. Alertness as such weight loss is not expected: This response may unnecessarily alarm the mother when, in fact, some weight loss in the early days is normal.

B. Reassurance as this is a normal weight loss.

It is normal for newborns to lose some weight during the first few days of life. The loss is often related to fluid loss, changes in feeding patterns, and initial adjustment to life outside the womb. A loss of one-half pound in a 2-day-old neonate is generally considered within the normal range. It's important for the nurse to reassure the new mother that this weight loss is expected and not a cause for alarm. Newborns typically start to regain their birth weight within a week or two. This reassurance can help ease the mother's distress and anxiety.

C. Alarm as this is a drastic weight loss: Characterizing this weight loss as "drastic" is not accurate or helpful and would likely increase the mother's anxiety.

D. Concern as this may be an indicator of inadequate nutrition: Jumping to the conclusion of inadequate nutrition without further assessment and evidence is premature and may unnecessarily worry the mother. It's important to start with reassurance and then investigate if there are concerns about nutrition.

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Correct Answer is D

Explanation

A. Checking urine for glucose and protein is not directly related to the care of a child with a VP shunt. The focus is on monitoring the child for signs of complications related to the shunt.

B. Administering narcotics for pain control may be indicated if the child is in pain, but it is not the primary action and should be determined based on the child's pain assessment.

C. Testing cerebrospinal (CSF) fluid leakage for protein is not typically a nursing responsibility in the immediate postoperative period. Leakage of CSF should be reported to the healthcare provider, and diagnostic tests would be conducted by medical staff as needed.

D. Monitor for increased temperature.

Monitoring for an increased temperature is essential because postoperative fever could be an early sign of infection or complications related to the VP shunt. Infection and shunt malfunction are potential risks in the postoperative period.

A. 1 day B. 8 to 10 days C. 5 to 7 days D. 2 to 3 days

Correct Answer is C

Explanation

A. Introducing new foods every day does not allow sufficient time to monitor for adverse reactions.

B. Waiting 8 to 10 days between introducing new foods is a longer interval than typically recommended. It may unnecessarily delay the introduction of a variety of foods to the infant's diet.

C. 5 to 7 days.

When introducing new foods to an infant, it's important to do so gradually to monitor for any potential allergic reactions or sensitivities. Waiting 5 to 7 days between introducing new foods allows for observation of any adverse reactions, such as allergies or digestive issues. This approach helps in identifying the specific food responsible for any adverse reactions and ensures the infant's safety.

D. Waiting 2 to 3 days is too short of an interval to adequately monitor for adverse reactions. Waiting 5 to 7 days provides a better balance between introducing new foods and monitoring for potential issues.

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The new mother of a 2-day-old neonate who weighed 8 pounds at birth is distressed that the baby has lost one-half pound. The home health nurse's response is one of:

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Which action should the nurse take when providing postoperative nursing care to a child after insertion of ventriculoperitone (VP) shunt?

Correct Answer is D

Explanation

New foods should be introduced to the infant at intervals of

Correct Answer is C

Explanation

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