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 C

Explanation

Choice A rationale:

Fentanyl is an opioid analgesic and is not used to counteract the effects of meperidine in the newborn. Both fentanyl and meperidine are opioids, and using fentanyl in this context would not counteract the effects of meperidine.

Choice B rationale:

Flumazenil is a medication used to reverse the effects of benzodiazepines, not opioids like meperidine. It is not appropriate for countering the effects of meperidine in the newborn.

Choice C rationale:

Naloxone is an opioid antagonist that can reverse the effects of opioids like meperidine. When a newborn has been exposed to opioids during labor, such as meperidine given to the mother, there is a risk of respiratory depression in the newborn. Naloxone can quickly reverse this effect and restore normal respiratory function.

Choice D rationale:

Benztropine is an anticholinergic medication used to treat side effects of antipsychotic drugs and is not relevant in this situation. It would not counteract the effects of meperidine on the newborn.

A. Prepare the equipment necessary to initiate an amnioinfusion. B. Administer oxygen at 10 L/min via a nonrebreather face mask. C. Discontinue the infusion of oxytocin. D. Place the client in a left lateral position.

Correct Answer is D

Explanation

Choice A reason:

Preparing for an amnioinfusion is not the first-line action. It may be considered if decelerations do not resolve with initial measures such as maternal repositioning.

Choice B reason:

Administering oxygen is a subsequent measure if initial interventions like repositioning do not improve the FHR. Oxygen is typically given at 8-10 L/min via a nonrebreather mask to increase fetal oxygenation.

Choice C reason:

Discontinuing oxytocin is important if the cause of decelerations is uterine hyperstimulation. However, repositioning the client should precede this action to quickly address potential umbilical cord compression.

Choice D reason:

This is the first action to take because it can quickly alleviate potential compression of the umbilical cord, which is often the cause of variable decelerations. It may be considered if decelerations do not resolve with initial measures such as maternal repositioning.

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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 laboring client received meperidine IV one hour prior to delivery. Which of the following medications should the nurse have available to counteract the effects of this medication on the newborn?

Correct Answer is C

Explanation

A nurse is caring for a client who is receiving oxytocin to augment labor. The nurse notes recurrent variable decelerations of the FHR. Which of the following actions should the nurse take first?

Correct Answer is D

Explanation

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