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.
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 C
Explanation
Choice C rationale:
The nurse should first massage the client's fundus to address the excessive vaginal bleeding. Massaging the fundus helps the uterus contract and prevents further bleeding. Excessive postpartum bleeding may indicate uterine atony, which is a leading cause of postpartum hemorrhage. The nurse should apply gentle pressure to the fundus to promote uterine contractions and reduce bleeding.
Choice A rationale:
Elevating the client's legs to a 30° angle (Trendelenburg position) is not the priority action in this situation. Fundal massage takes precedence because it directly addresses the cause of the excessive bleeding. While Trendelenburg position might be used in some situations to increase blood flow to vital organs, it is not the first-line intervention for postpartum bleeding.
Choice B rationale:
Inserting an indwelling urinary catheter is not the priority action for excessive vaginal bleeding. While monitoring urine output is essential, the immediate concern is controlling the bleeding by massaging the fundus.
Choice D rationale:
Initiating an infusion of oxytocin may be indicated if fundal massage alone is insufficient to control bleeding. However, massaging the fundus should be the first action taken to promote uterine contractions. Oxytocin can be administered afterward, if needed, under the direction of a healthcare provider.
Correct Answer is B
Explanation
Choice A rationale:
In Rh incompatibility, if the mother's blood does not contain the Rh factor (Rh-negative) and she is exposed to Rh-positive blood (usually from the fetus during delivery), her immune system may produce anti-Rh antibodies. However, these antibodies do not typically cross the placental barrier during the first pregnancy. Rh incompatibility occurs when the mother's blood is Rh- negative, and she is carrying an Rh-positive fetus during her second or subsequent pregnancies, leading to sensitization and potential hemolysis in future pregnancies.
Choice B rationale:
This choice is correct. Rh incompatibility occurs when the mother is Rh-negative, and the newborn is Rh-positive. During the first pregnancy, the mother is not sensitized to the Rh factor and does not produce significant amounts of anti-Rh antibodies. However, if the fetus is Rh- positive, there is a risk of sensitization during childbirth or any other event where maternal and fetal blood may mix. In subsequent pregnancies, if the mother becomes pregnant with another Rh-positive fetus, her immune system will recognize the Rh antigen as foreign and produce antibodies that can cross the placenta and attack the fetal red blood cells, leading to hemolysis and hyperbilirubinemia in the newborn.
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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