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.

Answer and Explanation

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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Correct Answer is D

Explanation

Choice A rationale

The largest fetal diameter passing through the pelvic outlet is not what is indicated by the presenting part being at 0 station. This would be more indicative of a positive station, such as

+31.

Choice B rationale

The position of the fetal head, such as left occiput posterior, is not determined by the station of the presenting part. The station refers to the level of the presenting part in relation to the mother’s ischial spines.

Choice C rationale

The palpability of the posterior fontanel is not related to the station of the presenting part. The fontanels are soft spots on the baby’s head which allow for compression during birth and brain growth after birth.

Choice D rationale

This is the correct interpretation of the clinical finding. The presenting part is at 0 station when its lowermost portion is at the level of an imaginary line drawn between the client’s ischial spines.

A. Meconium aspiration syndrome due to the color of amniotic fluid. B. Birth weight. C. Gestational age. D. Fetal Undergrowth Anomaly (FUA). .

Correct Answer is A

Explanation

The correct answer is Choice A........ Therefore, it poses the greatest risk to a newborn who is 30

minutes old.

Choice B rationale

Birth weight can influence a newborn’s health, with low birth weight associated with various health problems. However, it is less immediately life-threatening compared to meconium aspiration syndrome.

Choice C rationale

Gestational age can influence a newborn’s health, with preterm birth associated with various health problems. However, it is less immediately life-threatening compared to meconium aspiration syndrome.

Choice D rationale

Fetal Undergrowth Anomaly (FUA) refers to a condition where a fetus does not grow at the expected rate during pregnancy. It can lead to various health problems for the newborn. However, it is less immediately life-threatening compared to meconium aspiration syndrome.

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Choice A rationale

Choice B rationale

Choice C rationale

Choice D rationale

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is assessing a client who is in active labor and notes that the presenting part is at 0 station. Which of the following is the correct interpretation of this clinical finding?

Correct Answer is D

Explanation

Choice B rationale

Choice C rationale

Choice D rationale

A nurse is caring for a newborn who is 30 minutes old. After reviewing the information in the newborn’s medical record, which of the following complications should the nurse identify as posing the greatest risk?

Correct Answer is A

Explanation

Choice B rationale

Choice C rationale

Choice D rationale

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A nurse is caring for a client during the first trimester of pregnancy. After reviewing the client’s blood work, the nurse notices she does not have immunity to rubella. When should the nurse understand is the recommended time for rubella immunization?

A nurse is preparing to measure the fundal height of a client who is at 22 weeks of gestation. At which location should the nurse expect to palpate the fundus?

A nurse is admitting a client who is at 30 weeks of gestation and is in preterm labor. The client has a new prescription for betamethasone and asks the nurse about the purpose of this medication. Which of the following explanations should the nurse provide?

A nurse is caring for a newborn who is 30 minutes old. After reviewing the information in the newborn’s medical record, which of the following complications should the nurse identify as posing the greatest risk?