A nurse is caring for a client who is at 40 weeks of gestation and is in labor. The client's ultrasound examination indicates that the fetus is small for gestational age (SGA). Which of the following interventions should be included in the newborn's plan of care?
Identify manifestations of anemia.
Monitor for hyperglycemia.
Observe for meconium in respiratory secretions.
Monitor for hyperthermia
The Correct Answer is C
Rationale: A) Identify manifestations of anemia: While anemia can occur in newborns, especially in premature infants or those with specific maternal conditions, it is not necessarily a primary concern for infants who are small for gestational age (SGA). SGA infants are more at risk for issues related to intrauterine growth restriction (IUGR) and complications such as meconium aspiration syndrome (MAS) due to fetal distress, rather than anemia.
B) Monitor for hyperglycemia: SGA infants are at higher risk for hypoglycemia rather than hyperglycemia, particularly due to limited glycogen stores and increased metabolic demands after birth. Therefore, monitoring for and managing hypoglycemia is a more pertinent intervention for SGA newborns than monitoring for hyperglycemia.
C) Observe for meconium in respiratory secretions: SGA infants, who are born below the 10th percentile for their gestational age, are at increased risk for intrauterine hypoxia and stress, which can lead to meconium aspiration syndrome (MAS). Meconium aspiration occurs when the newborn inhales meconium-stained amniotic fluid, potentially causing airway obstruction and respiratory distress. Therefore, closely observing for meconium in respiratory secretions is crucial for timely intervention and management if MAS is suspected.
D) Monitor for hyperthermia: While hyperthermia can occur in newborns due to various reasons, including environmental factors and infection, it is not specifically associated with being born small for gestational age. Monitoring for hyperthermia is important in all newborns, but it is not a primary concern specifically related to SGA infants.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Respiratory depression: This is the correct choice. Magnesium sulfate can depress the central nervous system, which can lead to respiratory depression. This is a serious side effect and should be reported to the provider immediately.
B. Drowsiness: While drowsiness can occur with magnesium sulfate use, it is not typically a sign of toxicity. However, if drowsiness is severe or accompanied by other symptoms, it should be reported to the provider.
C. Nausea: Nausea can occur with magnesium sulfate use, but it is not typically a sign of toxicity. However, if nausea is severe or accompanied by other symptoms, it should be reported to the provider.
D. Facial flushing: Facial flushing can occur with magnesium sulfate use, but it is not typically a sign of toxicity. However, if facial flushing is severe or accompanied by other symptoms, it should be reported to the provider.
Correct Answer is A
Explanation
A. “This occurs because newborns lack muscle control to regulate eye movements”: This is the correct answer. Newborns often have uncoordinated eye movements because the muscles that control their eyes are not fully developed yet. This is normal and usually resolves by the time the baby is about 3 months old.
B. “This is a concern, but strabismus is easily treated with patching”: This response is not entirely accurate. While strabismus can be treated with patching, it’s important to note that crossing of the eyes in newborns is usually normal and does not necessarily indicate strabismus.
C. “I will take your baby to the nursery for further examination”: This response may cause unnecessary worry for the mother. It’s better to reassure the mother that this is a normal occurrence in newborns.
D. “I will call your primary care provider to report your concerns”: This response may also cause unnecessary worry for the mother. The nurse should first reassure the mother that this is a normal occurrence in newborns.
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