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 B
Explanation
A. Inform the client the anesthetic effect will last for approximately 6 hours: This is not the priority nursing action following an amniotomy. Anesthesia may not even be used during an amniotomy, and the duration of its effect varies depending on the type and individual response.
B. Obtain a 30 min electronic fetal monitoring (EFM) strip prior to induction: This is the correct choice. It’s important to assess the baseline fetal heart rate and any existing decelerations or accelerations before the procedure. This can help identify any potential distress the fetus may experience during the procedure.
C. Administer a 500 mL bolus of 5% dextrose in water prior to induction: While hydration is important during labor, it is not the priority nursing action following an amniotomy. The need for a fluid bolus would be based on the client’s individual condition and provider’s orders.
D. Have the client stand at the bedside with her arms at her side: This is not the priority nursing action following an amniotomy. The client’s position would be determined by her comfort and the stage of labor, but it is not the first action a nurse should take after an amniotomy.
Correct Answer is A
Explanation
A. "You seem scared to talk to your parents”: This is the correct answer. The nurse is using therapeutic communication to acknowledge the client’s feelings and encourage further discussion.
B. "Give your parents a chance they’ll understand”: This response is not therapeutic as it minimizes the client’s feelings and does not acknowledge the client’s fear or concern.
C. "If you want me to, I can tell your parents for you”: This response is not appropriate because it does not respect the client’s right to privacy and confidentiality.
D. "Your parents will have to be told why you are being admitted”: This response is not correct because it violates the client’s right to confidentiality. The nurse should not disclose any information without the client’s consent.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.