Practice Question
A nurse is caring for a newborn who is 5 days old. Which of the following actions are needed? Select all that apply.
Answer Choices:
Correct Answer:
Weigh the newborn daily.
Rationale:
Weigh the newborn daily
🍼 Daily weights (same time, same scale, same clothing/diaper) provide an objective trend of intake and hydration in the first week of life.
🍼 A normal physiologic weight loss is ≤7–10% by day 3–5 with regain by ~2 weeks; crossing these limits signals feeding problems or dehydration.
🍼 Early identification of excess weight loss prompts lactation support, feed frequency adjustments, or evaluation for underlying illness.
🍼 Weight trends correlate with other markers (e.g., wet diapers, stool frequency, clinical vigor), improving clinical decision-making.
🍼 Consistent measurement technique reduces error and ensures that subtle changes are detected early before complications develop.
Instruct the parent to avoid discomfort (minimize overstimulation)
🍼 Newborns have immature neurologic regulation; bright lights, loud noise, and excess handling increase energy expenditure and feeding fatigue.
🍼 Teaching caregivers to cluster care, use soft voices, and pace interactions preserves sleep architecture and supports growth.
🍼 Reducing overstimulation lowers stress cues (finger splay, color change, yawning/hiccups) and stabilizes heart rate, respirations, and temperature.
🍼 Comfort-promoting strategies (skin-to-skin, cue-based feeds, gentle rocking) decrease crying and improve feeding readiness.
🍼 The goal is to keep the newborn in a quiet-alert state for feeding and to protect sleep, which is crucial for neurodevelopment.
Swaddle the newborn for comfort
🍼 Swaddling provides containment that mimics the intrauterine environment, reducing Moro (startle) reflex and crying.
🍼 Proper technique (arms contained, hips flexed/abducted to avoid dysplasia, no overheating) improves self-soothing and sleep duration.
🍼 By decreasing stress and caloric burn, swaddling supports weight gain and thermoregulation.
🍼 Swaddling before painful or stimulating care can reduce procedural distress and help with state regulation.
🍼 Parents should be taught safe swaddling and to stop when rolling begins to maintain safe sleep practices.
Maintain a low-stimulation environment
🍼 A dim, quiet environment with gentle handling helps maintain physiologic stability (color, tone, respirations), especially in the first days.
🍼 Low stimulation conserves glycogen stores and reduces oxygen demand, supporting euglycemia and temperature control.
🍼 Pairing a calm setting with skin-to-skin and cue-based feeding improves milk transfer and maternal–infant bonding.
🍼 Minimizing alarms, limiting visitors, and spacing cares prevent sensory overload that can disrupt feeding and sleep–wake cycles.
🍼 This approach fosters neurobehavioral organization, which underpins effective feeding, growth, and early learning.
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This question is from RN-Maternal Newborn 2023 which contains 68 questions.
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Question Details
- Category: RN Nursing Exam(s)
- Subcategory: ATI Exam(s)
- Domain: RN ATI Maternal & Newborn Care
- Answer Choices: 6