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. Encourage the client to empty her bladder every 2 hr.: This is the correct choice. A full bladder can impede the descent of the fetus and can increase the client’s discomfort. Therefore, it’s important to encourage the client to empty her bladder regularly.
B. Remind the client to bear down with each contraction: This is not recommended during the active phase of the first stage of labor. The client should be instructed to bear down only during the second stage of labor when the cervix is fully dilated.
C. Maintain the client in the lithotomy position: This is not necessary during the active phase of the first stage of labor. The lithotomy position is typically used during the second stage of labor for the actual delivery of the baby. During the first stage, the client should be encouraged to find a comfortable position.
D. Perform vaginal examinations frequently: This is not recommended. Frequent vaginal examinations increase the risk of introducing infection. Vaginal examinations should be performed only when necessary to assess the progress of labor.

Correct Answer is ["5"]

Explanation

The Apgar score is calculated based on five components: heart rate, respiratory effort, muscle tone, reflex irritability, and color. Each component is scored from 0 to 2, with 2 being the best score. Here’s how this newborn’s Apgar score adds up:

Heart Rate: A slow, weak cry suggests a heart rate less than 100 beats per minute, which scores a 1.

Respiratory Effort: A slow, weak cry also suggests that the baby’s respiratory effort is slow or irregular, which scores a 1.

Muscle Tone: Some flexion of extremities indicates some muscle tone, but not completely normal, which scores a 1.

Reflex Irritability: A grimace in response to suctioning at the nares indicates some reflex irritability, which scores a 1.

Color: A body pink in color with blue extremities indicates that the baby is not completely pink, which scores a 1.

Adding these scores together, the newborn’s Apgar score at 1 minute after delivery is 5 units.

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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?

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Naxlex Comprehensive Predictor Exams

A nurse is caring for a client following an amniotomy, who is now in the active phase of the first stage of labor. Which of the following actions should the nurse implement with this client?

Correct Answer is A

Explanation

A nurse is caring for a newborn and calculating the Apgar score at 1 minute after delivery, the following findings are noted: Slow, weak cry Some flexion of extremities Grimace in response to suctioning at the nares Body pink in color Blue extremities Calculate the newborn's Apgar score.

Correct Answer is ["5"]

Explanation

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