A nurse is caring for a newborn.
The newborn was delivered via cesarean birth approximately 1 hr ago.
The Apgar Scores are 8 and 9. Vitamin K was administered in the left vastus lateralis.
The weight is 4337 grams (9 lb 9 oz), length 52 cm (20.5 in), and gestational age assessment of 39 weeks. The newborn is large for gestational age and noted to be jittery and have decreased muscle tone. Complete the diagram by dragging from the choices below to specify what condition the newborn is most likely experiencing, two actions the nurse should take to address that condition, and two parameters the nurse should monitor to assess the newborn’s progress.
Check the newborn’s capillary blood glucose level.
Place the newborn under a radiant warmer.
Monitor the newborn’s temperature.
Monitor the newborn’s color and frequency of bowel movements.
The Correct Answer is A,B,C
Choice A rationale
Checking the newborn’s capillary blood glucose level is important, especially for a large for gestational age newborn. Large for gestational age newborns are at risk for hypoglycemia (low blood sugar) after birth. Therefore, regular monitoring of the newborn’s blood glucose level is crucial.
Choice B rationale
Placing the newborn under a radiant warmer can help regulate the baby’s body temperature. Newborns, especially those who are large for gestational age, may have difficulty maintaining their body temperature after birth. A radiant warmer can provide the extra warmth the baby needs.
Choice C rationale
Monitoring the newborn’s temperature is important as newborns can lose heat rapidly, they don’t have the ability to control their body temperature as adults do. Temperature regulation in newborns is important to help them stay healthy and comfortable.
Choice D rationale
Monitoring the newborn’s color and frequency of bowel movements is not directly related to the condition described. While it’s an important aspect of newborn care, it’s not a priority in this scenario.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A rationale
While congenital anomalies, growth restriction, and fetal distress during labor can occur in pregnancies, they are not directly associated with polyhydramnios. Polyhydramnios is a condition characterized by an excessive accumulation of amniotic fluid in the uterus during pregnancy.
Choice B rationale
Carrying more than one fetus can lead to a condition known as twin-to-twin transfusion syndrome, which can result in polyhydramnios in one twin and oligohydramnios in the other. However, carrying more than one fetus does not directly mean the mother will experience polyhydramnios.
Choice C rationale
Polyhydramnios is indeed characterized by an excessive amount of amniotic fluid present in the uterus during pregnancy. This can be due to various reasons such as fetal abnormalities, maternal diabetes, and others.
Choice D rationale
An elevated level of alpha-fetoprotein (AFP) in the amniotic fluid can be an indication of certain fetal abnormalities, but it is not a direct indicator of polyhydramnios.
Correct Answer is C
Explanation
Choice A rationale
The patient’s anti-A and anti-B antibodies crossing the placenta and causing the destruction of the fetal red blood cells is related to ABO incompatibility, not Rh incompatibility.
Choice B rationale
If the patient’s blood contains the Rh factor and the newborn’s does not, Rh incompatibility would not occur. Rh incompatibility happens when the mother’s blood does not contain the Rh factor (Rh-negative), but the baby’s blood does contain the Rh factor (Rh-positive).
Choice C rationale
The patient’s blood does not contain the Rh factor, so she produces anti-Rh antibodies that cross the placental barrier and cause hemolysis of red blood cells in newborns. This is the correct reason for hyperbilirubinemia occurring with Rh incompatibility.
Choice D rationale
The patient’s blood containing anti-Rh antibodies that attack the newborn’s red blood cells is a result of Rh incompatibility, but it does not explain why hyperbilirubinemia occurs.
Hyperbilirubinemia occurs due to the breakdown of the extra red blood cells, leading to an increase in bilirubin levels.
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