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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale
Heart rate of 170. A heart rate of 170 is not a symptom of transient tachypnea of the newborn.
Choice B rationale
Grunting or sighing with respirations. This is a symptom of transient tachypnea of the newborn.
Choice C rationale
Nasal flaring. This is a symptom of transient tachypnea of the newborn.
Choice D rationale
Respirations of 72. This is a symptom of transient tachypnea of the newborn.
Correct Answer is B
Explanation
Choice A rationale
While the fundus at the level of the umbilicus is a normal finding for a woman who is 4 hours postpartum, it is not the priority in this case. The fundus, which is the top part of the uterus, typically descends at a rate of approximately one fingerbreadth (or one cm) per day, and by the 12th postpartum day, it should no longer be palpable.
Choice B rationale
A saturated perineal pad in 30 minutes is a sign of excessive bleeding, also known as postpartum hemorrhage. This is a serious condition that can lead to shock and other complications if not treated promptly. Therefore, this finding should be prioritized by the nurse.
Choice C rationale
Approximated edges of an episiotomy are a normal finding in the postpartum period. An episiotomy is a surgical incision made in the perineum to enlarge the vaginal opening for delivery. After delivery, the episiotomy is sutured and should heal without complications with proper care. However, this is not the priority finding in this scenario.
Choice D rationale
Deep tendon reflexes 4+ could be a sign of preeclampsia, a pregnancy complication characterized by high blood pressure and signs of damage to another organ system, often the liver and kidneys. However, since the client is already 4 hours postpartum, this is less likely to be the priority.
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