which action should the nurse take if an infant who was born yesterday weighing 75 lbs 3402 grams weighs 7 lbs 3175 grams today
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Nursing Elites

HESI RN

Maternity HESI 2023 Quizlet

1. What action should the nurse take if an infant, who was born yesterday weighing 7.5 lbs (3,402 grams), weighs 7 lbs (3,175 grams) today?

Correct answer: A

Rationale: The correct action for the nurse to take in this situation is to inform and assure the mother that this weight loss is normal. Newborns can lose up to 10% of their birth weight in the first few days after birth, which is attributed to fluid loss and adjustment to life outside the womb. This weight loss is typically regained within the first two weeks of life. It is crucial for the nurse to educate and provide reassurance to the mother about this common occurrence in newborns.

2. An off-duty healthcare professional finds a woman in a supermarket parking lot delivering an infant while her husband is screaming for someone to help his wife. Which intervention has the highest priority?

Correct answer: D

Rationale: Putting the newborn to breast is the highest priority intervention in this scenario. It helps stimulate uterine contractions in the mother, which aids in controlling postpartum bleeding. Additionally, placing the newborn to breast promotes bonding between the mother and infant, provides comfort to the baby, and facilitates the initiation of breastfeeding. Ensuring the well-being of both the mother and the newborn is essential in this critical situation.

3. A woman who gave birth 48 hours ago is bottle-feeding her infant. During assessment, the nurse determines that both breasts are swollen, warm, and tender upon palpation. What action should the LPN/LVN take?

Correct answer: A

Rationale: After childbirth, engorgement of the breasts can occur, leading to swelling and discomfort. Applying cold compresses helps reduce swelling and provides comfort for engorged breasts. This action can also help with pain relief and promote milk flow regulation. Instructing the client to run warm water on her breasts (Choice B) is incorrect as warm water can increase blood flow and exacerbate swelling. Wearing a loose-fitting bra (Choice C) may provide some comfort, but it does not address the swelling effectively. Expressing small amounts of milk (Choice D) may provide temporary relief but does not address the underlying issue of engorgement.

4. During a newborn assessment, which symptom would indicate respiratory distress if present in a newborn?

Correct answer: A

Rationale: Flaring of the nares is a classic sign of respiratory distress in newborns. It indicates that the newborn is working hard to breathe, and immediate attention should be given to assess and address the respiratory status of the infant.

5. To confirm respiratory distress syndrome (RDS) in a newborn, what should the nurse assess?

Correct answer: A

Rationale: To confirm respiratory distress syndrome (RDS) in a newborn, the nurse should assess diaphragmatic breathing. In RDS, the baby may have difficulty breathing due to immature lungs, leading to shallow, rapid breathing movements. Assessing diaphragmatic breathing directly evaluates the respiratory effort and can help identify the presence of RDS. Choice B, assessing heart sounds, is not specific to diagnosing RDS but could be relevant for other conditions. Choice C, monitoring blood oxygen levels, is important but alone may not confirm RDS. Choice D, checking for signs of infection, is not a direct indicator of RDS but rather suggests a different issue.

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