The nurse is assessing a 40-week small for gestational age (SG
Positive Moro and stepping reflexes.
Scant vernix in the groin and underarms.
Heel stick of 65 and a serum blood glucose of 40.
Tenting of the skin and dry lips.
The Correct Answer is D
Choice A rationale
Positive Moro and stepping reflexes are normal findings in newborns and are not specifically associated with dehydration or SGA.
Choice B rationale
Scant vernix is common in full-term babies and not indicative of SGA or dehydration.
Choice C rationale
Blood glucose levels provided are within normal range for newborns and do not indicate dehydration.
Choice D rationale
Tenting of the skin and dry lips are signs of dehydration, which can be associated with SGA newborns due to insufficient fluid intake. .
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","B","C","D"]
Explanation
Choice A rationale
Respiratory assessment is vital, especially following childbirth, to ensure the mother is not experiencing respiratory issues.
Choice B rationale
Monitoring hemoglobin levels can help identify significant blood loss during delivery, which can lead to anemia and other complications.
Choice C rationale
A heart rate that is elevated postpartum may indicate underlying issues such as infection or hemorrhage, which need to be reported.
Choice D rationale
Continuous blood trickling from the vagina is a warning sign of potential postpartum hemorrhage, which is a medical emergency.
Correct Answer is D
Explanation
Choice A rationale
Placing the newborn in a radiant warmer is appropriate for managing hypothermia but does not directly address the signs of diaphoresis, jitteriness, and lethargy, which are indicative of hypoglycemia.
Choice B rationale
Monitoring the newborn's blood pressure is not the primary action needed for signs of hypoglycemia. The immediate need is to check blood glucose levels and address any hypoglycemia.
Choice C rationale
Initiating phototherapy is a treatment for hyperbilirubinemia (jaundice) and is not related to the signs of diaphoresis, jitteriness, and lethargy seen in hypoglycemia.
Choice D rationale
Obtaining blood glucose by heel stick is the correct action as the signs of diaphoresis, jitteriness, and lethargy are indicative of hypoglycemia. Checking blood glucose levels will help in diagnosing and managing the condition.
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