A nurse is planning care for a newborn who is small for gestational age (SGA) Which of the following is the priority intervention the nurse should include in the newborn's plan of care?

Monitor fluid intake.

Monitor axillary temperature.

Monitor blood glucose levels.

Monitor weight.

Answer and Explanation

The Correct Answer is C

Choice A rationale:

Monitoring fluid intake is important for any newborn, but it is not the priority intervention for a small for gestational age (SGA) newborn. SGA infants are at risk of hypoglycemia due to limited glycogen stores, and monitoring blood glucose levels is crucial in identifying and managing hypoglycemia.

Choice B rationale:

Monitoring axillary temperature is essential for all newborns to assess their thermoregulation. However, it is not the priority intervention for an SGA newborn. Hypoglycemia is a more immediate concern and must be addressed promptly.

Choice C rationale:

Monitoring blood glucose levels is the priority intervention for an SGA newborn. As mentioned earlier, SGA infants are at higher risk of hypoglycemia, which can lead to serious complications if not managed appropriately. By monitoring blood glucose levels, the nurse can detect and address hypoglycemia early.

Choice D rationale:

Monitoring weight is important for tracking the growth and development of the newborn, but it is not the priority intervention in this scenario. The immediate concern for an SGA newborn is their blood glucose levels.

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Correct Answer is D

Explanation

Choice A rationale:

Decreasing fiber intake is not a recommended action for urinary incontinence. Fiber intake is related to bowel health and does not directly affect urinary incontinence.

Choice B rationale:

Avoiding Kegel exercises is not recommended for urinary incontinence. Kegel exercises are beneficial for strengthening the pelvic floor muscles, which can help improve urinary continence.

Choice C rationale:

Restricting fluid intake to 1 liter per day is not advisable for urinary incontinence. Adequate hydration is essential for overall health, and limiting fluid intake can lead to dehydration and other health issues.

Choice D rationale:

Reducing intake of caffeinated and carbonated beverages is a helpful recommendation for a client experiencing urinary incontinence. Caffeine and carbonation can irritate the bladder and worsen incontinence symptoms.

A. The client's blood does not contain the Rh factor, so she produces anti-Rh antibodies that cross the placental barrier and cause hemolysis of red blood cells in newborns. B. The client's blood contains the Rh factor, and the newborn's does not, and antibodies that destroy red blood cells are formed in the fetus. C. The client has a history of receiving a transfusion with Rh-negative blood. D. The client's anti-A and anti-B antibodies cross the placenta and cause the destruction of the fetal red blood cells.

Correct Answer is A

Explanation

Choice A rationale:

Rh incompatibility occurs when an Rh-negative client is exposed to Rh-positive fetal blood, typically during a prior pregnancy or delivery. The client’s immune system produces anti-Rh antibodies that cross the placenta in subsequent pregnancies, attacking the Rh-positive red blood cells of the fetus. This hemolysis releases bilirubin, leading to hyperbilirubinemia in the newborn.

Choice B rationale:

Rh incompatibility only occurs when the client is Rh-negative and the fetus is Rh-positive. An Rh-positive client will not form antibodies against an Rh-negative fetus, as their immune system recognizes the Rh factor as normal.

Choice C rationale:

This choice is not related to the mechanism of Rh incompatibility. Receiving a transfusion with Rh-negative blood would not cause the mother's immune system to produce anti-Rh antibodies or lead to Rh incompatibility with her newborn.

Choice D rationale:

This choice describes the ABO blood group system, not the Rh factor. ABO incompatibility can occur when a mother with blood type O (producing anti-A and anti-B antibodies) has a newborn with blood type A, B, or AB, leading to hemolysis of the fetal red blood cells. However, the question specifically mentions Rh incompatibility, which involves the Rh factor, not the ABO system.

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A nurse is planning care for a newborn who is small for gestational age (SGA) Which of the following is the priority intervention the nurse should include in the newborn's plan of care?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who is experiencing urinary incontinence. Which of the following recommendations should the nurse include in the teaching plan for this client?

Correct Answer is D

Explanation

A nurse is caring for a client who has just delivered her first newborn. The nurse anticipates hyperbilirubinemia due to Rh incompatibility. The nurse should understand that hyperbilirubinemia occurs with Rh incompatibility for which of the following reasons?

Correct Answer is A

Explanation

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