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. A fundus palpable to the right of midline may indicate a distended bladder pushing the uterus to the side, and it requires intervention to promote bladder emptying.
B. Less than 2.5 cm of rubra lochia on a perineal pad is a normal finding in the early postpartum period.
C. Increased thirst is not directly indicative of bladder distention.
D. Frequent uterine contractions are expected in the postpartum period and do not necessarily indicate bladder distention.

A. Webbing B. Clubfoot C. Hip dysplasia D. Polydactyly

Correct Answer is C

Explanation

A. Webbing typically refers to the presence of extra skin between body parts and is not associated with uneven skinfolds on the buttocks or a clunk during the Ortolani maneuver.
B. Clubfoot refers to a deformity of the foot and is not associated with uneven skinfolds on the buttocks or hip abnormalities.
C. Uneven skinfolds on the buttocks and a clunk during the Ortolani maneuver are indicative of hip dysplasia in a newborn.
D. Polydactyly refers to the presence of extra fingers or toes and is unrelated to the described findings.

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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 2 hr postpartum following a vaginal birth. Which of the following findings indicates the client's bladder is distended?

Correct Answer is A

Explanation

While examining a newborn, the nurse notes uneven skinfolds on the buttocks and a clunk when performing the Ortolani maneuver. These findings are likely indicative of what?

Correct Answer is C

Explanation

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