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

Answer and Explanation

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.

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Correct Answer is C

Explanation

A. Increase in blood pressure: Methylergonovine can cause an increase in blood pressure, but this is a side effect of the medication, not an indication of its effectiveness.

B. Report of absent breast pain: Methylergonovine is not typically used to treat breast pain, so this would not be an indication of its effectiveness.

C. Fundus firm to palpation: This is the correct answer. Methylergonovine is a medication used to prevent or control postpartum hemorrhage by causing the uterus to contract. A firm fundus upon palpation indicates that the uterus is contracting effectively, which is the desired effect of the medication.

D. Increase in lochia: An increase in lochia (vaginal discharge after childbirth) is not an indication of the effectiveness of Methylergonovine. In fact, heavy lochia can be a sign of postpartum hemorrhage, which the medication is intended to prevent. Therefore, an increase in lochia would not indicate that the medication is working effectively.

A. Blood pressure 80/56 mm Hg B. Temperature 38.2°C (100.8") C. The client reports weakness of the low D. The client reports perfuse itching

Correct Answer is A

Explanation

A. Blood pressure 80/56 mm Hg: This is the correct answer. This blood pressure is low and could indicate hypotension, a common side effect of epidural analgesia. Hypotension can compromise both maternal and fetal circulation, making it the priority finding.

B. Temperature 38.2°C (100.8"): While this temperature is slightly elevated, it is not as immediately concerning as hypotension. The nurse should continue to monitor the client’s temperature and report any significant increases.

C. The client reports weakness of the low: If the client is reporting lower extremity weakness, this could be a side effect of the epidural analgesia. However, it is not as immediately concerning as hypotension.

D. The client reports perfuse itching: Itching can be a side effect of opioid medications. However, it is not as immediately concerning as hypotension. The nurse can report this to the provider and may be able to administer medication to relieve the itching if necessary.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who is postpartum and received Methylergonovine. Which one of the following findings indicate that the medication was effective?

Correct Answer is C

Explanation

A nurse is caring for a client who is receiving opioid epidural analgesia during labor. Which one of the following findings is the nurse’s priority?

Correct Answer is A

Explanation

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