The nurse is caring for an infant who is small for her gestational age (SGA). Which intervention is of highest priority for this infant who is at risk for hypoglycemia?

Ensure the infant breastfeeds in the first hour.

Perform a glucose test for the infant before feeding.

Administer intravenous dextrose infusion within 2 hours.

Ensure the infant is fed every hour for the first 24 hours.

Answer and Explanation

The Correct Answer is A

A.   This intervention is correct because it provides the infant with a source of glucose and helps prevent hypoglycemia.
B.   A glucose test alone may not provide timely intervention if hypoglycemia is detected.
C. Administering intravenous dextrose infusion is a rapid and effective way to address hypoglycemia, but early breastfeeding should be the priority action.
D.   While frequent feeding is beneficial, intravenous dextrose may be necessary for a more immediate impact.

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Correct Answer is A

Explanation

A. Breast milk typically comes in 3 to 5 days postpartum.
B. This timeline is too early for the onset of mature breast milk.
C. This timeline is too late for the onset of mature breast milk.
D. This timeline is too late for the onset of mature breast milk.

A. Document the findings and continue to monitor the client. B. Encourage the client to empty her bladder. C. Increase the frequency of fundal massage. D. Notify the client’s provider.

Correct Answer is A

Explanation

A. The presence of lochia rubra with small clots in the immediate postpartum period is expected. The firm and midline fundus indicates appropriate uterine contraction. Continued monitoring is appropriate.
B. Encouraging the client to empty her bladder is a valid intervention, but it is not the priority in this situation.
C. Increasing the frequency of fundal massage is unnecessary, as the fundus is already firm.
D. Notifying the provider is not necessary based on the described findings, as they are within the expected range.

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The nurse is caring for an infant who is small for her gestational age (SGA). Which intervention is of highest priority for this infant who is at risk for hypoglycemia?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who is postpartum who asks the nurse when her breast milk will "come in." Which of the following responses should the nurse make?

Correct Answer is A

Explanation

A nurse is caring for a client who is 1 hr postpartum and observes a large amount of lochia rubra and several small clots on the client’s perineal pad. The fundus is midline and firm at the umbilicus. Which of the following actions should the nurse take?

Correct Answer is A

Explanation

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