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 A
Explanation
Choice A rationale
Surfactant reduces alveolar surface tension, improving lung compliance and facilitating gas exchange of oxygen and carbon dioxide, critical in addressing respiratory distress syndrome in premature infants.
Choice B rationale
Periodic apnea in premature infants is a neurological immaturity issue, not directly addressed by surfactant, which targets alveolar function in the lungs.
Choice C rationale
Surfactant does not possess antimicrobial properties; it functions to stabilize alveoli, not to combat respiratory infections.
Choice D rationale
Sedation requirements for infants are unrelated to surfactant therapy, which works mechanically in the lungs rather than through central nervous system effects.
Correct Answer is B
Explanation
Choice A rationale
A pulse rate of 80 and regular does not directly indicate Methergine's effectiveness. Normal pulse ranges from 60 to 100 beats per minute. This could result from overall stabilization rather than medication effect.
Choice B rationale
A firm uterine fundus at the umbilicus and moderate lochia indicate effective uterine contraction and hemostasis, reflecting successful intervention with Methergine in managing postpartum hemorrhage.
Choice C rationale
A blood pressure of 120/80 is within the normal adult range but does not specifically reflect Methergine's uterotonic action. Blood pressure monitoring is essential but not the primary efficacy indicator.
Choice D rationale
An increase in prothrombin time reflects coagulation changes but is unrelated to Methergine's mechanism of action. It focuses on hemostatic effects via uterine contractions rather than coagulation pathways.
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