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    Hesi rn n404 maternity and pediatrics proctored exam

    Which 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?

    Explanation & Rationale

    Rationale: A. Monitor the stool and urine output of the neonate for the last 24 hours: Monitoring elimination patterns is important to assess hydration and feeding adequacy. However, a weight loss of approximately 6% from birth is within the expected physiologic range and does not require immediate intervention. B. Inform and assure the mother that this is a normal weight loss: Newborns typically lose 5–10% of their birth weight during the first 3–5 days due to fluid shifts and limited initial intake. The nurse’s priority is to reassure the mother, explain that this is expected, and continue supporting regular feeding. C. After verifying the accuracy of the weight, notify the healthcare provider: Notifying the healthcare provider is necessary if the weight loss exceeds 10% of birth weight or if there are signs of dehydration. In this case, the loss is within the normal range. D. Encourage the mother to increase frequency of breastfeeding: Increasing feeding frequency is important if the infant shows inadequate intake or excessive weight loss. Since the weight loss is physiologic and expected, routine feeding patterns can continue.

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