A nurse is caring for a newborn who is large for gestational age and is 12 hours old.
Which of the following laboratory tests should the nurse monitor based on the client's condition?

Bilirubin.

Glucose.

White blood cell count.

Arterial blood gases.

Answer and Explanation

The Correct Answer is B

Choice A rationale

Bilirubin monitoring is critical for jaundice due to hemolysis, often seen in ABO incompatibility or cephalohematoma. While Large for Gestational Age (LGA) infants can have polycythemia, hypoglycemia is a more immediate and life-threatening risk that requires priority monitoring in the first hours of life. The normal total bilirubin range is typically less than 5 mg/dL in the first 24 hours.

Choice B rationale

LGA infants are often born to mothers with uncontrolled or gestational diabetes, leading to fetal hyperinsulinism. After birth, the maternal glucose supply is cut off, and the high insulin levels persist, causing a rapid and profound drop in the newborn's blood glucose, hence hypoglycemia is a major concern. The normal newborn glucose range is 40 to 60 mg/dL and should be monitored.

Choice C rationale

White blood cell (WBC) count is primarily monitored to detect neonatal sepsis or infection. While all newborns are at risk, the LGA classification does not inherently place them at a higher, unique risk for infection compared to the immediate metabolic derangement risks like hypoglycemia. The normal WBC count range is 9,000 to 30,000 cells/mm.

Choice D rationale

Arterial Blood Gases (ABGs) are used to assess the newborn's respiratory status and acid-base balance, particularly in respiratory distress syndrome or persistent pulmonary hypertension. While LGA infants can experience birth trauma or meconium aspiration, ABG monitoring is not routine unless significant respiratory symptoms are present.

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Correct Answer is C

Explanation

Choice A rationale

A transvaginal fetal Doppler probe is an internal device used early in pregnancy to confirm fetal viability or heart rate in the first trimester, not an appropriate method for continuous intrapartum monitoring in a full-term client with intact membranes.

Choice B rationale

The DeLee-Hillis fetoscope is an external acoustic device used for intermittent auscultation of the fetal heart rate, providing a listening assessment rather than the prescribed continuous electronic tracing required for this client.

Choice C rationale

An external ultrasound transducer monitor (or tocodynamometer for contractions) uses non-invasive Doppler technology placed on the client's abdomen to detect and continuously monitor the fetal heart rate and uterine contractions when membranes are intact, satisfying the continuous monitoring prescription without internal access.

Choice D rationale

An internal fetal scalp electrode (FSE) requires the rupture of membranes and sufficient cervical dilation for placement onto the fetal scalp to provide a precise electrocardiogram of the fetal heart, which is not applicable since the client's membranes are intact.

A. Moderate maternal bleeding B. Client reports ringing in ears C. Client reports sharp, stabbing abdominal pain D. BP 180/100 mm Hg E. FHR 80/min with absent variability F. PT 12 seconds

Correct Answer is {"A":{"answers":"C"},"B":{"answers":"C"},"C":{"answers":"C"},"D":{"answers":"C"},"E":{"answers":"C"},"F":{"answers":"B"}}

Explanation

Explanation

Moderate maternal bleeding
- In a patient with HELLP and thrombocytopenia, bleeding suggests coagulopathy (DIC) or placental abruption. This is a serious worsening sign.
Ringing in ears (tinnitus)
- Could be a side effect of magnesium sulfate toxicity or a neurological symptom of worsening preeclampsia. Either way, it’s concerning and not a sign of improvement.
Sharp, stabbing abdominal pain
- RUQ/epigastric pain worsening into sharp pain raises concern for liver capsule distension or rupture (life-threatening complication of HELLP) or placental abruption. This is a red flag.
BP 180/100 mm Hg
- Despite antihypertensive therapy, this is severe hypertension (≥160/110 mm Hg). Indicates poor control and worsening maternal risk.
FHR 80/min with absent variability
- This is severe fetal bradycardia with no variability, indicating fetal hypoxia/distress. This is an obstetric emergency.
PT 12 seconds
- Within normal range (11–13.5 sec). This suggests no current coagulopathy and is the only stable/improving finding.

Almost all findings point to worsening maternal and fetal condition, except for the PT which is stable. The nurse should immediately notify the provider, anticipate emergency delivery (likely induction or cesarean), and continue close monitoring for magnesium toxicity and bleeding complications.

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A nurse is caring for a newborn who is large for gestational age and is 12 hours old. Which of the following laboratory tests should the nurse monitor based on the client's condition?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a full-term client in labor who is prescribed continuous fetal monitoring. On examination, the nurse determines the client's membranes are intact. Which of the following assessment methods should the nurse implement?

Correct Answer is C

Explanation

ExhibitsThe nurse is assessing the client 15 minutes later. How should the nurse interpret the following findings?

Correct Answer is {"A":{"answers":"C"},"B":{"answers":"C"},"C":{"answers":"C"},"D":{"answers":"C"},"E":{"answers":"C"},"F":{"answers":"B"}}

Explanation

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A nurse is caring for a newborn who is large for gestational age and is 12 hours old.
Which of the following laboratory tests should the nurse monitor based on the client's condition?