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 A

Explanation

A. The client’s blood does not contain the Rh factor so she produces anti- Rh antibodies that cross the placenta barrier and cause hemolysis of red blood cells in newborns: This is the correct answer. If the mother is Rh-negative and the baby is Rh-positive, the mother’s body may produce antibodies against the baby’s blood. These antibodies can cross the placenta and cause hemolysis (destruction) of the baby’s red blood cells, leading to hyperbilirubinemia.

B. The client’s anti-A and ant-B antibodies cross the placenta and cause the destruction of the fetal red blood cells: This is not correct. Anti-A and anti-B antibodies are related to the ABO blood group system, not the Rh system.

C. The client’s blood contains the Rh factor and the newborns does not, and antibodies that destroy the red blood cells are formed in the fetus: This is not correct. It is when the mother is Rh-negative and the baby is Rh-positive that there is a risk of Rh incompatibility.

D. The client has a history of receiving a transfusion with Rh-negative blood: This is not correct. A history of receiving a transfusion with Rh-negative blood would not cause Rh incompatibility in a subsequent pregnancy. Rh incompatibility is caused by a difference in Rh factor between the mother and baby.

A. Monitor vital signs every 5 min. B. Place the client in a lateral position C. Notify the provider. D. Elevate the client’s legs

Correct Answer is B

Explanation

A. Monitor vital signs every 5 min: While monitoring vital signs is important, it is not the priority action. The client’s blood pressure is low, which could be due to the epidural anesthesia. The priority is to manage the client’s blood pressure.

B. Place the client in a lateral position: This is the correct choice. Placing the client in a lateral position can help improve blood flow and increase blood pressure. This is often the first step in managing hypotension following epidural anesthesia.

C. Notify the provider: While it’s important to notify the provider of changes in the client’s condition, the nurse should first take action to manage the client’s blood pressure.

D. Elevate the client’s legs: While this can help increase venous return and improve blood pressure, it is not the first action the nurse should take. The priority is to change the client’s position to improve blood flow and increase blood pressure. Elevating the legs can be done after repositioning the client if blood pressure remains low.

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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

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Correct Answer is A

Explanation

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Correct Answer is B

Explanation

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