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. Diabetes Insipidus is associated with reduced ADH levels, leading to excessive urination and dehydration, not hyponatremia.
B. Acromegaly results from excessive growth hormone (not ADH) secretion, causing abnormal growth of tissues and bones.
C. Addison's disease involves the adrenal glands and the insufficient production of cortisol and aldosterone, not ADH-related hyponatremia.
D. Syndrome of Inappropriate Antidiuretic Hormone (SIADH).
SIADH is a disorder characterized by the excessive release of antidiuretic hormone (ADH) from the posterior pituitary gland, leading to increased water reabsorption by the kidneys. This results in diluted blood and hyponatremia (low sodium levels) due to the retention of water. Patients with SIADH often experience fluid overload and related symptoms.
Correct Answer is D
Explanation
A. Get 8 hours of sleep at night and take naps during the day:
While adequate sleep is generally important for overall health, it may not be the most critical factor for a patient with aplastic anemia. Aplastic anemia primarily affects blood cell production, and managing infection risk and blood counts are more crucial in this context.
B. Practice yoga and meditation to decrease stress and anxiety:
Stress reduction techniques, such as yoga and meditation, can be beneficial for anyone's overall well-being, but it's not the top priority for someone with aplastic anemia. Managing stress is essential, but again, reducing the risk of infections and maintaining adequate blood counts are more critical.
C. Eat animal protein and dark leafy vegetables each day:
Proper nutrition is essential for patients with aplastic anemia, as it can help support the production of red blood cells and maintain overall health. However, while a balanced diet is important, avoiding infections and minimizing exposure to contagions is more pressing.
D. Avoid exposure to others with acute infection:
This is the most crucial concept for patients with aplastic anemia. Aplastic anemia leads to a weakened immune system, making the patient highly susceptible to infections. Exposure to individuals with acute infections can be life-threatening for these patients. Preventing infections and maintaining adequate blood counts are paramount in the care of individuals with aplastic anemia.
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