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
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
In transposition of the great vessels (TGV), the aorta and the pulmonary artery are switched, causing oxygen-rich blood to be pumped back to the lungs and oxygen-poor blood to be pumped out to the body. The ductus arteriosus, a fetal blood vessel that normally closes shortly after birth, allows blood to mix between the two circulations.
Prostaglandin E1 is used to keep the ductus arteriosus open, allowing for a controlled mixing of oxygenated and deoxygenated blood, which can improve oxygen delivery to the body in cases of TGV. This helps maintain oxygenation until corrective surgical interventions can be performed.
The other options, A (decrease pulmonary congestion), B (stimulate the production of red blood cells), and D (increase blood flow to the system), do not accurately describe the primary purpose of Prostaglandin E1 in the context of TGV. The main goal is to maintain a pathway for oxygenated blood to mix with deoxygenated blood to improve oxygen delivery to the body.
Correct Answer is D
Explanation
A. Administration of a systemic oral antibiotic and a topical antibiotic may be used, but this option does not address the removal of crusts, which is essential for preventing complications.
B. Administration of a systemic and a topical antifungal is not appropriate for impetigo, as impetigo is caused by bacteria, not fungi.
C. Using an oil-based soap for bathing is not recommended, as it may not effectively remove crusts and pustules associated with impetigo, and it does not have antimicrobial properties necessary for treatment.
D. Removal of crusts with an antimicrobial liquid.
Impetigo is a contagious bacterial skin infection, typically caused by Staphylococcus aureus or Streptococcus pyogenes. It often presents with crusts and pustules on the skin. To prevent complications, it's important to keep the affected areas clean and free from crusts. Gently removing crusts with an antimicrobial liquid and clean cloth helps prevent the spread of infection, allows topical antibiotics to work effectively, and reduces the risk of complications.
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