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
A. "Have you spoken to your mother about these feelings’’: While family support can be helpful, it’s not the nurse’s place to suggest who the client should talk to about her feelings. Each person’s support system is unique and personal.
B. "Perhaps you should see a counsellor to discuss these feelings further”: While professional help can be beneficial, suggesting it as the first response may make the client feel that her feelings are abnormal or something to be concerned about.
C. "Ambivalent feelings are quite common for women early in pregnancy”: This is the correct choice. It’s important to normalize the client’s feelings. Pregnancy, especially the first one, is a significant life event filled with changes. It’s completely normal to have mixed feelings and doubts.
D. “Don’t worry. You will be fine once the baby is born”: This response dismisses the client’s feelings and concerns. It’s important to validate the client’s feelings rather than minimizing them. Every person’s experience with pregnancy and parenthood is unique, and it’s not helpful to make assumptions about how the client will feel in the future.
Correct Answer is C
Explanation
A. Apply petroleum jelly to the cord stump: This is not recommended. Applying petroleum jelly can create a moist environment, which can delay the drying and falling off of the cord stump.
B. Wash the cord daily with mild soap and water: This is not necessary. The cord stump should be kept dry to promote healing and prevent infection. Washing it daily with soap and water can delay the drying process.
C. Give a sponge bath until the cord stump falls off: This is the correct choice. Sponge baths are recommended until the cord stump falls off and the area is healed. This helps to keep the cord stump dry and clean, which promotes healing and prevents infection.
D. Cover the cord with the diaper: This is not recommended. The diaper should be folded down so that the cord stump is exposed to air, which helps it dry out and fall off. Covering the cord stump with the diaper can keep it moist and delay the healing process. It can also expose the stump to urine and feces, which can lead to infection.
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