A nurse is planning care for a newborn who is large for gestational age. Which of the following actions should the nurse include in the plan of care? (Select all that apply.)

Check the newborn's skin for ecchymosis.

Assist the mother to breastfeed the newbom after birth.

Obtain a stool sample of meconium.

Assist with administering a blood transfusion to the newborn.

Check the newborn's blood glucose level.

Answer and Explanation

Correct Answer : A,B,E

A)   Correct - Checking the newborn's skin for ecchymosis can help identify potential birth-related injuries, as large-for-gestational-age newborns might experience more trauma during delivery.
B)   Correct - Breastfeeding can help regulate the newborn's blood glucose levels and provide necessary nutrients.
C)   Incorrect- Meconium is the early stool passed by a newborn and might be checked for various reasons but is not specifically related to a large-for-gestational-age newborn.
D)   Incorrect- Administering a blood transfusion to a newborn is not typically a part of the care plan for large-for-gestational-age newborns.
E)   Correct- The nurse should check the newborn's blood glucose level regularly and provide interventions as needed.

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Correct Answer is D

Explanation

The correct answer is d. "I may develop discoloration on my cheeks from hormonal changes."

Choice a rationale:

Statement:"I should expect to have burning when I urinate during the third trimester."
Rationale:This statement is incorrect.Burning during urination is not a normal physiological change of pregnancy.It may be a sign of a urinary tract infection (UTI),which is a common infection during pregnancy.If a pregnant client experiences burning during urination,she should report it to her healthcare provider for evaluation and treatment.

Choice b rationale:

Statement:"I may have an infection if I develop a dark line in the middle of my abdomen."
Rationale:This statement is incorrect.A dark line in the middle of the abdomen,known as the linea nigra,is a normal physiological change of pregnancy.It is caused by hormonal changes that increase melanin production in the skin.The linea nigra typically appears in the second trimester and fades after delivery.

Choice c rationale:

Statement:"I should expect my fingers and face to be swollen."
Rationale:This statement is partially correct.Some swelling in the hands and face is common during pregnancy,especially in the third trimester.This is due to fluid retention caused by hormonal changes.However,excessive swelling,particularly in the hands and face,can be a sign of preeclampsia,a serious pregnancy complication.It's important to report any significant swelling to a healthcare provider.

Choice d rationale:

Statement:"I may develop discoloration on my cheeks from hormonal changes."
Rationale:This statement is correct.Hormonal changes during pregnancy can cause a variety of skin changes,including melasma,which is a brownish discoloration that often appears on the cheeks,forehead,and nose.Melasma is more common in women with darker skin tones and usually fades after delivery.

A. Administer the medication into the deltoid muscle. B. Administer the medication 12 hr after birth. C. Administer the medication with a 25-gauge needle. D. Check the mother's Rh factor prior to administration.

Correct Answer is C

Explanation

A) Incorrect- Administering medication into the deltoid muscle is not typically done in newborns. Phytonadione is given intramuscularly, usually in the vastus lateralis muscle, not the deltoid muscle.
B) Incorrect- Phytonadione should be given within 1 hour of birth, not 12 hours after birth. Delaying the administration increases the risk of bleeding complications.
C) Correct- The size of the needle is important for the newborn's comfort, A 25-gauge needle is the appropriate size for administering phytonadione to a newborn. A smaller needle may not deliver the medication adequately, and a larger needle may cause more tissue damage and bleeding.
D) Incorrect- The mother's Rh factor is irrelevant for the administration of phytonadione.

Rh factor affects the risk of hemolytic disease in the newborn, which is a different condition from hemorrhagic disease.

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A nurse is planning care for a newborn who is large for gestational age. Which of the following actions should the nurse include in the plan of care? (Select all that apply.)

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse in a prenatal clinic is reinforcing teaching with a client about expected physiological changes during pregnancy. Which of the following statements by the client indicates an understanding of the teaching?

Correct Answer is D

Explanation

A nurse is preparing to administer phytonadione to a newborn. Which of the following actions should the nurse take?

Correct Answer is C

Explanation

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