A nurse is assessing a post-term infant who was born with intrauterine growth restriction (IUGR).

Which of the following findings should the nurse expect?

Large head in proportion to body size.

Loose, peeling skin without lanugo or vernix.

Increased subcutaneous fat and muscle mass.

Hypertonia and hyperreflexia.

Answer and Explanation

The Correct Answer is B

Loose, peeling skin without lanugo or vernix is a symptom of post-term infants who have intrauterine growth restriction (IUGR). Post-term infants are born after 42 weeks of gestation and may have reduced placental function, resulting in less nutrition and oxygen for the fetus. This can cause them to have low birth weight, decreased subcutaneous fat and muscle mass, and dry skin.

Choice A is wrong because a large head in proportion to body size is not a sign of IUGR. It may indicate a congenital anomaly or a chromosomal disorder.

Choice C is wrong because increased subcutaneous fat and muscle mass are not signs of IUGR. They are signs of normal fetal growth and development.

Choice D is wrong because hypertonia and hyperreflexia are not signs of IUGR. They may indicate a neurological problem or a perinatal asphyxia (lack of oxygen during birth).

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Correct Answer is A

Explanation

This is because hypoglycemia in newborns can cause seizures, brain damage, and developmental delays, and frequent monitoring can help detect and correct low blood glucose levels promptly.

Some additional information about the other choices are:

Choice B. Administer glucagon subcutaneously as prescribed.This is wrong because glucagon is used to treat hypoglycemia caused by hyperinsulinism, which is a rare condition in newborns.Most cases of hypoglycemia in term infants are due to transient factors such as delayed feeding, maternal diabetes, or perinatal stress.

Choice C. Discontinue IV dextrose when blood glucose reaches 60 mg/dL.This is wrong because 60 mg/dL is still below the normal range of blood glucose for newborns, which is 70 to 100 mg/dL.Discontinuing IV dextrose too early can cause rebound hypoglycemia and increase the risk of neurologic complications.

Choice D. Feed breast milk or formula every four hours.This is wrong because feeding every four hours may not be enough to maintain adequate blood glucose levels in newborns with hypoglycemia.Infants with hypoglycemia should be fed more frequently, such as every two to three hours, or on demand.Breast milk or formula can also be supplemented with IV dextrose if needed.

A. The newborn’s skin color is pink B. The newborn’s stools are clay-colored C. The newborn’s bilirubin level is 12 mg/dL D. The newborn’s urine is dark yellow.

Correct Answer is A

Explanation

The newborn’s skin color is pink.This indicates that the phototherapy is effective in lowering the serum bilirubin level by transforming it into water-soluble isomers that can be eliminated without liver conjugation.

A pink skin color also means that the newborn is not jaundiced, which is a sign of high bilirubin levels.

Choice B is wrong because clay-colored stools indicate a problem with the liver or bile ducts.Bile is needed to give stools their normal brown color, and if bile is absent or blocked, the stools may become pale or clay-colored.This could be a sign of a serious condition such as biliary atresia, which is a congenital defect that causes bile ducts to be absent or malformed.

Choice C is wrong because a bilirubin level of 12 mg/dL is still high for a newborn and may require further treatment.The American Academy of Pediatrics recommends phototherapy for newborns with bilirubin levels above 15 mg/dL at 25 to 48 hours of age, 18 mg/dL at 49 to 72 hours of age, and 20 mg/dL at more than 72 hours of age.However, these thresholds may vary depending on the gestational age, risk factors, and clinical condition of the newborn.

Choice D is wrong because dark yellow urine may indicate dehydration or concentrated urine, which can increase the risk of bilirubin toxicity.Newborns receiving phototherapy should be well hydrated and have frequent wet diapers to help eliminate bilirubin from the body.Normal urine color for a newborn is pale yellow or clear.

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A nurse is assessing a post-term infant who was born with intrauterine growth restriction (IUGR). Which of the following findings should the nurse expect?

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Naxlex Comprehensive Predictor Exams

A nurse is planning care for a post-term infant who has hypoglycemia and is receiving IV dextrose solution. Which of the following interventions should the nurse include in the plan?

Correct Answer is A

Explanation

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Correct Answer is A

Explanation

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A nurse is assessing a post-term infant who was born with intrauterine growth restriction (IUGR).

Which of the following findings should the nurse expect?