Author Question: A 1-week-old infant is in the pediatric clinic. The birth weight was 8 lb, 1 oz (3.65 kg). Today the ... (Read 41 times)

meagbuch · **on:** Jun 28, 2018

A 1-week-old infant is in the pediatric clinic. The birth weight was 8 lb, 1 oz (3.65 kg). Today the infant weighs 7 lb (3.17 kg). The mother breastfeeds exclusively. What action by the nurse is best?

A.
Assess the mother's breastfeeding technique.
B.
Document the finding and alert the provider.
C.
Reassure the woman that weight loss is normal.
D.
Refer the mother to a lactation consultant.

Question 2

A teenager is in the family practice clinic for a school physical. When the parent leaves the room, the teen admits to cutting myself after a relative touched me in my private area. What action by the nurse is most appropriate?

A.
Document the statements and alert the provider.
B.
Explain that this information must be shared.
C.
Have the secretary call the police department.
D.
Reassure the teen of confidentiality rules.

amynguyen1221 · **Reply #1 on:** Jun 28, 2018

Answer to Question 1

ANS: B
Newborns often lose 5-10 of their birth weight during the first week of life. However, a weight loss greater than 10 needs further evaluation. This baby has lost just over 10 of birth weight. The nurse should document the finding and alert the health-care provider. Assessing breastfeeding technique and referral to a lactation consultant may be appropriate depending on the etiology of the problem. The nurse should not reassure the mother that the weight loss is normal because it is excessive for the first week of life.

Answer to Question 2

ANS: B
Older children (teens and preteens) often prefer to be interviewed in private where concerns of a personal nature can be shared in a safe area. Information about sexuality is often discussed at this time. The nurse is responsible for maintaining privacy except in situations of abuse or where a life-threatening situation exists. The nurse should first explain to the teen that this information needs to be shared with the parent before doing anything else. The information does need to be documented and the provider alerted, but not as the priority. Each facility will have policies in place to report possible abuse, which may or may not involve calling the police, Child Protective Services, or a social worker. However, reporting will wait until the nurse explains to the teen that the information needs to be shared.