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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. Encourage the mother to increase frequency of breastfeeding: Encouraging more frequent feeds is important if weight loss exceeds the normal range or if feeding cues are not being met. In this case, the infant’s weight loss is within the expected 5–10% of birth weight during the first days of life. B. Monitor the stool and urine output of the neonate for the last 24 hours: Monitoring elimination patterns helps assess hydration status and feeding effectiveness. However, since the weight loss is within the physiologic range, this step is not the most immediate action. C. After verifying the accuracy of the weight, notify the healthcare provider: Notifying the provider is appropriate when weight loss is greater than 10% of birth weight or when the infant shows clinical signs of dehydration. In this case, the 6% loss is normal. D. Inform and assure the mother that this is a normal weight loss: Normal neonatal physiology includes losing 5–10% of birth weight in the first 3–5 days due to fluid shifts, limited intake, and initial adaptation. The nurse should reassure the mother, explain that this is expected, and continue to encourage routine feeding and monitoring.

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