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 C
Explanation
Answer: (C) 4-0-1-2-2
Rationale:
A) 2-0-0-2-0: This option is incorrect because it does not accurately represent the client's pregnancy history. The GTPAL system includes:
- G: Total number of pregnancies
- T: Number of term deliveries (after 37 weeks)
- P: Number of preterm deliveries (between 20 and 37 weeks)
- A: Number of pregnancies ending in spontaneous or elective abortion (before 20 weeks)
- L: Number of living children
For this client:
- G: 4 (one current pregnancy, one abortion, and twins plus one more spontaneous abortion)
- T: 0 (no deliveries at term)
- P: 2 (twins born at 36 weeks and another preterm delivery)
- A: 1 (one spontaneous abortion at 15 weeks)
- L: 2 (living children from the twins)
B) 3-0-2-0-2: This option is incorrect because it does not account for the total number of pregnancies or the number of pregnancies ending in abortion accurately.
C) 4-0-1-2-2: This option is correct because it accurately represents the client's pregnancy history:
- G (Gravida): 4 (including the current pregnancy and all past pregnancies)
- T (Term deliveries): 0 (no deliveries at term)
- P (Preterm deliveries): 2 (twins at 36 weeks and another preterm delivery)
- A (Abortions): 1 (spontaneous abortion at 15 weeks)
- L (Living children): 2 (twins)
D) 4-2-0-2-2: This option is incorrect because it misrepresents the number of term and preterm deliveries and does not account for the spontaneous abortion correctly.
Correct Answer is D
Explanation
A. “Do you think you could keep him in the nursery for the next feeding so I can get some sleep?”: This statement does not necessarily indicate an inhibition of parental attachment. The new mother may just be tired and need some rest, which is quite normal after childbirth.
B. “He’s got my husband’s nose, that’s for sure”: This statement indicates a positive parental attachment as the mother is identifying familial traits in her newborn.
C. “I don’t need a baby bath demonstration. I know how to do it”: This statement suggests that the mother is confident in her ability to care for her baby, which is a positive sign of parental attachment.
D. “I wish he had more hair. I will keep a hat on his head until he grows some”: This is the correct answer. This statement could indicate an inhibition of parental attachment as the mother seems to be focusing on a perceived imperfection in her baby rather than accepting and loving her baby as they are. It’s important to note that this is just one potential sign and should be considered in the context of other behaviors and interactions between the mother and baby.
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