A macrosomic infant is born after a difficult forceps-assisted delivery.
After stabilization, the infant is weighed, and the birth weight is 4550 g (9 lbs, 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.

Perform a gestational age assessment to determine whether the infant is large for gestational age.

Monitor blood glucose levels frequently and observe closely for signs of hypoglycemia.

Answer and Explanation

The Correct Answer is D

choice D. Monitor blood glucose levels frequently and observe closely for signs of hypoglycemia. This is because a macrosomic infant (a newborn who’s much larger than average) is at risk of developing low blood sugar levels after birth, especially if the mother has diabetes. Hypoglycemia can cause neurological damage in the newborn, so it is important to detect and treat it promptly.

Choice A is wrong because leaving the infant in the room with the mother without monitoring the blood glucose levels may miss signs of hypoglycemia and delay treatment.

Choice B is wrong because taking the infant immediately to the nursery may separate the infant from the mother and interfere with breastfeeding, which can help prevent hypoglycemia.

Choice C is wrong because performing a gestational age assessment to determine whether the infant is large for gestational age is not urgent and does not address the risk of hypoglycemia.

Normal ranges for blood glucose levels in term infants are 2.6 mmol/L or higher at any time. A blood glucose level of 2.5 mmol/L or less is considered hypoglycemic.

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Correct Answer is D

Explanation

An Apgar score of 10 at 1 minute after birth indicates that the infant is having no difficulty adjusting to extrauterine life but who should be assessed again at 5 minutes after birth. The Apgar score is a scoring system that evaluates the health of newborns at 1 and 5 minutes after birth based on five criteria: appearance, pulse, grimace, activity, and respiration. Each criterion is scored from 0 to 2, and the total score ranges from 0 to 10. A score of 7 to 10 is considered reassuring, a score of 4 to 6 is moderately abnormal, and a score of 0 to 3 is concerning.

Choice A is wrong because an Apgar score of 10 at 1 minute does not mean that the infant needs no further testing. The infant should still be assessed again at 5 minutes and monitored for any signs of distress or complications.

Choice B is wrong because an Apgar score of 10 at 1 minute does not indicate an infant in severe distress who needs resuscitation. An Apgar score of 0 to 3 would indicate a concerning condition that may require immediate intervention.

Choice C is wrong because an Apgar score of 10 at 1 minute does not predict a future free of neurologic problems. The Apgar score alone cannot be considered as evidence of, or a consequence of, asphyxia or brain injury; it does not predict individual neonatal mortality or neurologic outcome; and it should not be used for that purpose.

Normal ranges for each criterion are as follows:

Appearance (color): pink all over (2 points), body pink but extremities blue (1 point), blue, bluish-gray, or pale all over (0 points)
Pulse (heart rate): greater than 100 beats per minute (2 points), less than 100 beats per minute (1 point), absent (0 points)
Grimace (response to stimulation): cough or sneeze, cry and withdrawal of foot with stimulation (2 points), facial movement/grimace with stimulation (1 point), absent (0 points)
Activity (muscle tone): active movement (2 points), limbs flexed (1 point), limp or floppy (0 points)
Respiration (breathing): good, strong cry (2 points), irregular, weak crying (1 point), absent (0 points)

A. A normal finding B. An abnormal finding: the child needs referral to an ophthalmologist C. A sign of a possible visual defect; the child needs vision screening D. A sign of small hemorrhages, which usually resolve spontaneously

Correct Answer is A

Explanation

A brilliant, uniform red reflex in both eyes is a sign of a healthy retina and optic nerve. The red reflex is the reflection of light from the retina that varies in color depending on the patient’s skin tone. It can be seen by holding the ophthalmoscope directly in front of your eye and asking the patient to focus on a point in the distance.

Choice B is wrong because an abnormal finding would be an absent or asymmetric red reflex, which could indicate cataracts, retinal detachment, or other eye diseases.

Choice C is wrong because a possible visual defect would not affect the red reflex, but rather the visual acuity or field of vision of the patient.

A vision screening would involve testing the patient’s ability to read letters or numbers at different distances.

Choice D is wrong because small hemorrhages would not cause a brilliant, uniform red reflex, but rather dark spots or blotches on the retina that can be seen with the ophthalmoscope.

Hemorrhages can be caused by diabetes, hypertension, or trauma.

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A macrosomic infant is born after a difficult forceps-assisted delivery. After stabilization, the infant is weighed, and the birth weight is 4550 g (9 lbs, 6 ounces). The nurse’s most appropriate action is to:

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Naxlex Comprehensive Predictor Exams

An Apgar score of 10 at 1 minute after birth would indicate a(n):

Correct Answer is D

Explanation

During a funduscopic examination of a school-age child, the nurse notes a brilliant, uniform red reflex in both eyes. The nurse should recognize that this is:.

Correct Answer is A

Explanation

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A macrosomic infant is born after a difficult forceps-assisted delivery.
After stabilization, the infant is weighed, and the birth weight is 4550 g (9 lbs, 6 ounces). The nurse’s most appropriate action is to: