A macrosomic infant is born after a difficult forceps-assisted delivery.
After stabilization, the infant is weighed, and the birth weight is 4550 g (9 lbs, 6 ounces). The nurse’s most appropriate action is to:
Leave the infant in the room with the mother.
Take the infant immediately to the nursery.
Perform a gestational age assessment to determine whether the infant is large for gestational age.
Monitor blood glucose levels frequently and observe closely for signs of hypoglycemia.
The Correct Answer is D
choice D. Monitor blood glucose levels frequently and observe closely for signs of hypoglycemia. This is because a macrosomic infant (a newborn who’s much larger than average) is at risk of developing low blood sugar levels after birth, especially if the mother has diabetes. Hypoglycemia can cause neurological damage in the newborn, so it is important to detect and treat it promptly.
Choice A is wrong because leaving the infant in the room with the mother without monitoring the blood glucose levels may miss signs of hypoglycemia and delay treatment.
Choice B is wrong because taking the infant immediately to the nursery may separate the infant from the mother and interfere with breastfeeding, which can help prevent hypoglycemia.
Choice C is wrong because performing a gestational age assessment to determine whether the infant is large for gestational age is not urgent and does not address the risk of hypoglycemia.
Normal ranges for blood glucose levels in term infants are 2.6 mmol/L or higher at any time. A blood glucose level of 2.5 mmol/L or less is considered hypoglycemic.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["B","D"]
Explanation
Sleepiness or fatigue and puffiness around the eyes are symptoms associated with hypothyroidism. Hypothyroidism is a condition where the thyroid gland does not produce enough thyroid hormones, which regulate the body’s metabolism and energy levels.
Choice A is wrong because weight loss is more likely to occur in hyperthyroidism, a condition where the thyroid gland produces too much thyroid hormones.
Choice C is wrong because diarrhea is also more likely to occur in hyperthyroidism, as the excess thyroid hormones speed up the digestive system.
Choice E is wrong because limited hair growth is not a specific symptom of hypothyroidism. Hair loss or thinning may occur in both hypothyroidism and hyperthyroidism, depending on the severity and duration of the condition.
Normal ranges for thyroid hormones are:
- TSH: 0.4 to 4.0 mIU/L
- T3: 100 to 200 ng/dL
- T4: 4.5 to 11.2 mcg/dL
Correct Answer is C
Explanation
Children with asthma who are taking long-term inhaled steroids should be assessed frequently to monitor for this increased risk because some studies have shown a growth delay in children treated with moderate to high doses of inhaled steroids. This appears to occur only during the first year of treatment and may be reversible.
Choice A is wrong because cough is not a side effect of inhaled steroids, but a symptom of asthma itself.
Choice B is wrong because osteoporosis is not a common side effect of inhaled steroids in children, but a possible risk for adults who use high doses of inhaled steroids or oral steroids.
Choice D is wrong because Cushing’s syndrome is not a side effect of inhaled steroids, but a rare complication of oral steroids.
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