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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Related Questions
Correct Answer is D
Explanation
Choice A rationale
Applying cold compresses 20 minutes before each feeding may not be the most effective way to manage breast engorgement. Cold compresses can help to reduce swelling and relieve pain, but they do not address the underlying cause of engorgement, which is the accumulation of milk in the breasts.
Choice B rationale
Drinking herbal tea to reduce engorgement is not a proven method. While some herbs are believed to have galactagogue properties (increase milk production), they do not directly address breast engorgement. Furthermore, the safety and efficacy of many herbal remedies are not well-studied, and some may have side effects.
Choice C rationale
Letting the baby drain one breast at each feeding can help to alleviate engorgement, but it may not be sufficient if the feedings are spaced too far apart. The breasts continue to produce milk between feedings, and if the milk is not removed, engorgement can occur.
Choice D rationale
Feeding the baby every 2 hours can help to manage breast engorgement. Regular feedings help to ensure that the milk is being removed from the breasts, preventing the buildup that leads to engorgement.
Correct Answer is C
Explanation
Choice A rationale
Betamethasone does not increase the fetal heart rate. It is a corticosteroid given to pregnant women who are at risk of preterm delivery to enhance fetal lung maturity and prevent respiratory distress syndrome.
Choice B rationale
Betamethasone is not used to stop preterm labor contractions. Other medications, such as tocolytics, are used for this purpose.
Choice C rationale
This is the correct answer. Betamethasone is given to promote fetal lung maturity. It is usually given in two doses, 24 hours apart, and takes effect within 24 hours of administration.
Choice D rationale
Betamethasone does not halt cervical dilation. It is given to enhance fetal lung maturity, not to stop labor.
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