A nurse is formulating a care plan for a newborn who is small for gestational age (SGA). Which of the following should be the priority intervention in the newborn’s care plan?

Monitor weight.

Monitor I&O.

Monitor axillary temperature.

Monitor blood glucose levels.

Answer and Explanation

The Correct Answer is D

Choice A rationale

Monitoring weight is important for a newborn who is small for gestational age (SGA), but it is not the priority intervention. Weight can provide information about the newborn’s growth and development, but it does not address immediate physiological needs.
Choice B rationale
Monitoring I&O (Intake and Output) is crucial in assessing the newborn’s hydration status and kidney function. However, it is not the priority intervention for an SGA newborn.
Choice C rationale
Monitoring axillary temperature is important to maintain the newborn’s thermal regulation. However, it is not the priority intervention. Newborns, especially those who are SGA, are at risk for hypothermia due to their high body surface area to volume ratio and lack of subcutaneous fat.
Choice D rationale
Monitoring blood glucose levels is the priority intervention for an SGA newborn. SGA newborns are at risk for hypoglycemia because they have fewer glycogen stores. Hypoglycemia can lead to serious complications such as seizures, hence the need for close monitoring

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Correct Answer is B

Explanation

To calculate the estimated date of birth (EDB) using the first day of the last menstrual period (LMP), you can use Naegele’s Rule. This rule adds 280 days (or 40 weeks) to the first day of the LMP.

Given the LMP of July 27 (0727):

Add 1 year: July 27, 2023 becomes July 27, 2024.
Add 7 days: July 27, 2024 becomes August 3, 2024.
Subtract 3 months: August 3, 2024 becomes May 3, 2024.

So, the estimated date of birth (EDB) is May 3, 2024 (0503).

A. Place the client in a lateral position. B. Monitor vital signs every 5 minutes. C. Elevate the client’s legs. D. Notify the provider.

Correct Answer is A

Explanation

Choice A rationale
Placing the client in a lateral position can help improve blood flow to the uterus and placenta, which can help stabilize the client’s blood pressure and the fetal heart rate.
Choice B rationale
Monitoring vital signs every 5 minutes is important, but the priority action is to address the client’s low blood pressure, which can compromise blood flow to the fetus.
Choice C rationale
Elevating the client’s legs can help increase venous return and improve blood pressure, but it is not the priority action in this situation.
Choice D rationale
Notifying the provider is important, but the nurse should first take action to stabilize the client’s condition.

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A nurse is formulating a care plan for a newborn who is small for gestational age (SGA). Which of the following should be the priority intervention in the newborn’s care plan?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

What is the estimated date of birth (EDB) for a client who is pregnant and whose last menstrual period began on July 27? (State the date in MMDD. For example, July 27 is 0727)

Correct Answer is B

Explanation

A nurse is caring for a client who is in labor and has an epidural anesthesia block. The client’s blood pressure is 80/40 mm Hg and the fetal heart rate is 140/min. Which of the following is the priority nursing action?

Correct Answer is A

Explanation

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