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 B

Explanation

A) Incorrect- A 20-gauge needle is too large and could cause unnecessary pain for the newborn.
B) Correct - Choosing a 3/8-inch needle is appropriate for administering vaccines to newborns. he hepatitis B vaccine is given intramuscularly in the anterolateral thigh of newborns. The needle size should be appropriate for the muscle mass and age of the infant. A 3/8-inch needle is recommended for newborns, while a 20-gauge needle is too large and may cause tissue damage.
C) Incorrect- Administering the vaccine into the dorsal gluteal muscle is not recommended because of the risk of injury to the sciatic nerve; the recommended site is the vastus lateralis muscle in the anterolateral thigh.
D) Incorrect- The hepatitis B vaccine is usually administered in a dose of 0.5 mL for newborns, but this is not the only action that the nurse should take.

A. Abdominal breathing B. Grunting C. Respiratory rate 55/min D. Irregular respirations

Correct Answer is B

Explanation

A) Incorrect- Abdominal breathing is a normal pattern in newborns and does not require immediate reporting.
B) Correct - Grunting is a sign of respiratory distress in a newborn and should be reported to the provider for further evaluation.
C) Incorrect- A respiratory rate of 55/min is within the normal range for a newborn and does not require immediate reporting.
D) Incorrect- Irregular respirations are common in newborns and may not necessarily be indicative of a problem.

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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.)

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