Question

The nurse is assessing a newborn the day after birth. A high pitched cry, irritability and lack of interest in feeding are noted. The mother signed her own discharge against medical advice. What intervention is appropriate nursing care?

A) Reduce the environmental stimuli
B) Offer formula every 2 hours
C) Talk to the newborn while feeding
D) Rock the baby frequently

Answer 1

The appropriate nursing intervention for a newborn with a high-pitched cry, irritability, and lack of interest in feeding is to reduce environmental stimuli to minimize overstimulation. Once the infant is more settled, feeding can be reassessed.

Step-by-step explanation:

When assessing a newborn displaying a high-pitched cry, irritability, and a lack of interest in feeding, it is important to address these symptoms with appropriate interventions. The appropriate nursing care intervention would be to reduce the environmental stimuli. Since newborns can be easily overstimulated, creating a calming environment may help alleviate the newborn's distress. Lowering lights, minimizing noise and handling, and providing a swaddled, secure feeling can contribute to calming the infant.

While offering formula every two hours could address the lack of interest in feeding, it is essential first to recognize the likelihood that the high-pitched cry and irritability may be due to overstimulation rather than hunger. Rocking the baby frequently and talking to the newborn while feeding can be soothing, but if the irritability is due to overstimulation, these actions might exacerbate the situation before the environmental stimuli are controlled.