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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
This is because oil peppermint can stimulate the micturition reflex and help the woman to void.
Some possible explanations for the other choices are:
Choice A is wrong because pouring water over the perineum may not be enough to trigger the micturition reflex and may cause discomfort or infection.
Choice C is wrong because analgesics may not address the underlying cause of urinary retention and may have side effects such as drowsiness or nausea.
Choice D is wrong because inserting a sterile catheter is an invasive procedure that carries risks such as trauma, infection, or bladder spasms. It should be used only as a last resort after other methods have failed.
Normal ranges for postpartum bladder function are:
- Urine output: 3000 to 5000 mL/day for the first 2 to 3 days after delivery.
- Urine specific gravity: 1.005 to 1.030.
- Urine pH: 4.6 to 8.0.
Correct Answer is B
Explanation
If a child has acute epiglottitis, examination of the throat may cause complete obstruction and should be performed only when immediate intubation can take place.
This is because the inflamed epiglottis can block the airway and cause respiratory distress or failure.
Choice A is wrong because inspiratory stridor is a sign of upper airway obstruction that is aggravated when a child with epiglottitis is supine.
It is not caused by examining the throat with a tongue depressor.
Choice C is wrong because sore throat and pain on swallowing are early signs of epiglottitis, not precipitated by examining the throat with a tongue depressor.
Choice D is wrong because respiratory tract infection is the cause of epiglottitis, not a symptom or condition that is precipitated by examining the throat with a tongue depressor.
Epiglottitis is caused by H. influenzae in the respiratory tract.
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