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 C

Explanation

A. Obtaining a throat culture and B. visualizing the epiglottis with a tongue depressor are not safe actions for the nurse to perform without appropriate medical equipment and expertise. These actions can trigger a sudden airway obstruction in a child with epiglottitis. The priority is to ensure airway patency and seek immediate medical assistance.

C. Place the child in an upright position.

Suspected epiglottitis is a medical emergency that can result in rapid airway obstruction. Placing the child in an upright position helps improve airflow by allowing the throat to open and reduces the risk of complete airway obstruction. It's important not to perform invasive procedures (such as throat culture or visualization of the epiglottis) without proper medical equipment and expertise, as these actions can lead to worsening airway obstruction.

D. Transporting the child to radiology for a throat x-ray is not appropriate in this situation, as it may delay necessary interventions to secure the airway.

A. Provide activities for the sing to do at home B. Avoid interruptions by coordinating using actions C. Anwer questions honestly and clearly D. Encourage the sibling to write in a journal

Correct Answer is C

Explanation

A. Provide activities for the sibling to do at home: While providing activities can be a good way to engage the sibling and offer a distraction, it may not address their need for understanding and emotional support. Answering questions and providing information about the condition is more directly beneficial in this context.

B. Avoid interruptions by coordinating using actions: This option is not clear and may not directly address the social support needs of the sibling. It's important to have open communication and address their concerns rather than coordinating actions to avoid interruptions.

C. Answer questions honestly and clearly.

In a situation where a 10-year-old sibling of a child with a complex chronic condition needs social support, providing honest and clear answers to their questions is essential. It's important to address their concerns and provide information in an age-appropriate manner. Children can feel anxious or confused when a sibling has a complex chronic condition, and providing honest and clear answers helps them understand the situation better and reduces their anxiety.

D. Encourage the sibling to write in a journal: While journaling can be a helpful coping strategy, it may not be the most immediate response to their social support needs. Answering questions and providing emotional support should come first.

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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

A nurse is planning care for a child who has suspected epiglottitis. Which of the following actions should the nurse take

Correct Answer is C

Explanation

To meet the social support needs of a 10 year-old sibling of a child with a complex chronic condition, the most appropriate nursing action is to

Correct Answer is C

Explanation

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