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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A) Incorrect- Elevating a baby's head with a cushion during sleep is not recommended, as it can increase the risk of sudden infant death syndrome (SIDS) and obstructed breathing.
B) Correct - "I should replace the batteries in my smoke detector twice per year." Regularly replacing smoke detector batteries helps ensure they function properly in case of a fire emergency.
C) Incorrect- Setting the hot water heater to 130°F (54.4°C) is too hot and can cause scalding burns. The recommended temperature is 120°F (48.9°C) or lower.
D) Incorrect- Baby powder is not recommended for use with diaper changes, as it can be inhaled by the baby and lead to respiratory issues.
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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