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
Explanation
Brian playing with his truck next to Kristina playing with her truck. This is because parallel play is when children play side by side with similar toys but do not interact with each other. Parallel play is typical for toddlers and preschoolers.
Choice A is wrong because Kimberly and Amanda sharing clay to each make things is an example of cooperative play, which involves sharing, taking turns, and following
rules. Cooperative play is typical for school-age children.
Choice C is wrong because Adam playing a board game with Kyle, Steven, and Erich is also an example of cooperative play, as they are playing by the same rules and interacting with each other.
Choice D is wrong because Danielle playing with a music box on her mother’s lap is an example of solitary play, which is when a child plays alone and does not seek contact with others. Solitary play is typical for infants.
Correct Answer is D
Explanation
Therapeutic management includes the administration of gamma globulin and aspirin. This is because Kawasaki disease causes inflammation in the walls of small to medium-sized blood vessels that carry blood throughout the body and can lead to complications such as coronary artery aneurysms. Gamma globulin is an intravenous immunoglobulin that can reduce the risk of these complications, and aspirin can help lower fever and inflammation.
Choice A is wrong because the child’s fever is usually not responsive to antibiotics within 48 hours. Kawasaki disease is not caused by a bacterial infection, so antibiotics are not effective.
Choice B is wrong because the principal area of involvement is not the joints. Kawasaki disease affects mainly the blood vessels, but it can also cause swelling in glands (lymph nodes) and mucous membranes inside the mouth, nose, eyes and throat. Joint pain or swelling may occur, but it is not the main feature of the disease.
Choice C is wrong because aspirin is not contraindicated. Aspirin is part of the standard treatment for Kawasaki disease, along with gamma globulin. However, aspirin should be used with caution and under medical supervision, as it can cause Reye’s syndrome in children with viral infections.
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