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 D
Explanation
A.Pyloric stenosis is a condition where there's narrowing of the opening between the stomach and the small intestine. It is not related to inadequate motility of the intestine.
B.Enterocolitis refers to inflammation of the small intestine and colon. While this can cause obstruction in some cases, it's not the primary cause of inadequate motility as seen in the question.
C.Encopresis is the voluntary or involuntary passage of feces outside the toilet in children who should be toilet trained. It is not a cause of mechanical intestinal obstruction.
D. Hirschsprung's disease is a congenital disorder where there is inadequate motility in part of the intestine, leading to mechanical obstruction. It usually affects the colon and is due to the absence of ganglion cells in the affected segment of the bowel.
So, Hirschsprung's disease is the specific condition that leads to inadequate motility and mechanical obstruction of part of the intestine in infants.
Correct Answer is C
Explanation
Option A ("Considering the presence of diabetes but treating the child the same as the other children") is not the best approach because children with diabetes require individualized care and monitoring.
Option B ("Limiting fluid intake during school hours") is not an appropriate intervention and could potentially worsen the child's diabetes management. Hydration is important, and fluid intake should be based on the child's needs.
Option C. Asking the child each day what was eaten for breakfast.
Children with type 1 diabetes, especially those prone to morning hypoglycemic episodes, can benefit from close monitoring of their dietary choices and blood glucose levels. Asking the child what was eaten for breakfast allows the school nurse to assess whether the child had an appropriate meal and whether the insulin dosage may need adjustment. It helps identify potential factors contributing to hypoglycemia and provides valuable information for the child's diabetes management.
Option D ("Checking several times a day for injuries because of participation in the physical education program") is a good practice but does not specifically address the management of morning hypoglycemia. It is essential to monitor the child's safety during physical activities, but addressing breakfast choices and insulin management is more directly related to managing morning hypoglycemia.
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