A macrosomic infant is born after a difficult delivery. After stabilization, the infant is weighed, and the birth weight is 4550 g (9 pounds, 6 ounces). The nurse’s most appropriate action is to:
Leave the infant in the room with the mother.
Take the infant immediately to the nursery.
Monitor blood glucose levels frequently, and observe closely for signs of hypoglycemia.
Perform a gestational age assessment to determine if the infant is LGA.
The Correct Answer is C
Choice A rationale
Keeping the infant in the mother’s room without further evaluation increases the risk of missed complications like hypoglycemia. Monitoring and interventions are crucial for infants at risk due to macrosomia or difficult delivery.
Choice B rationale
Immediate nursery transfer without specific monitoring or intervention overlooks the infant’s risk for hypoglycemia and its symptoms, such as jitteriness or poor feeding. Further evaluation is more appropriate.
Choice C rationale
Macrosomic infants are at higher risk for hypoglycemia due to increased insulin levels post-birth. Frequent glucose monitoring and vigilance for signs like jitteriness or lethargy are crucial for timely intervention.
Choice D rationale
While gestational age assessment confirms LGA status, it does not address the immediate risk of hypoglycemia. Focus should remain on monitoring and stabilizing glucose levels in at-risk macrosomic infants.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale
Surgical intervention is not the initial step for uterine atony as conservative measures, such as fundal massage, are prioritized to encourage uterine contraction and reduce bleeding.
Choice B rationale
Fundal massage stimulates uterine contraction by mechanically compressing the myometrium, which helps to constrict the spiral arteries and reduce hemorrhage caused by uterine atony.
Choice C rationale
Establishing venous access is critical for fluid resuscitation but does not directly address the underlying cause of hemorrhage, which requires mechanical or pharmacological uterine contraction.
Choice D rationale
Catheterizing the bladder can prevent displacement of the uterus but does not directly address uterine atony. An empty bladder supports fundal massage by allowing proper uterine positioning.
Correct Answer is C
Explanation
Choice A rationale
Advising about birth defects without offering compassionate support can intensify parental grief and fails to acknowledge the significance of their emotional trauma, worsening their psychological response after a stillbirth.
Choice B rationale
Discouraging naming deters parental acknowledgment of their baby's existence, which disrupts grieving processes. Recognizing their loss helps families process grief healthily and facilitates emotional closure.
Choice C rationale
Giving mementos and allowing holding the baby fosters parental bonding and validates their loss. These actions are supported by bereavement care guidelines promoting emotional processing, acceptance, and closure after stillbirth.
Choice D rationale
Immediate morgue transport disregards the psychological needs of grieving parents and deprives them of opportunities to spend time with their baby, essential for acknowledging their loss and beginning grief processing.
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