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. Accelerations B. Late decelerations C. Variable decelerations D. Early decelerations

Correct Answer is C

Explanation

A. Accelerations: These are usually a good sign and indicate that the fetus is well-oxygenated.
B. Late decelerations: These are a sign of uteroplacental insufficiency, not a problem with the umbilical cord. They occur when the blood supply to the placenta is reduced during contractions, leading to a decrease in oxygen supply to the fetus.
C. Variable decelerations: This is the correct choice. Variable decelerations can be an indication of umbilical cord compression. They are called “variable” because they can occur at any time during the contraction cycle and can vary in depth and duration.
D. Early decelerations: These are usually benign and are often associated with fetal head compression during contractions, not a problem with the umbilical cord.

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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 observing the electronic fetal heart rate monitor tracing for a client who is at 40 weeks of gestation and is in labor. The nurse should suspect a problem with the umbilical cord when she observes which of the following patterns?

Correct Answer is C

Explanation

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