A nurse is assessing a client who is 4 hr postpartum following a vaginal delivery. Which of the following findings should the nurse identify as the priority?

Fundus at level of umbilicus

Saturated perineal pad in 30 min

Approximated edges of episiotomy

Deep tendon reflexes 4+

Answer and Explanation

The Correct Answer is D

A. Fundus is at level of the umbilicus is well contracted and therefore, not of concern.

B.   A saturated perineal pad in 15 min or less can indicate excessive bleeding.
C.   Approximated edges of episiotomy indicate proper wound repair and therefore, not of concern.
D.   Deep Tendon reflexes 4+ -4+ are hyperactive and indicate the client is at greatest risk for preeclampsia and seizures; this is the priority.

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Correct Answer is D

Explanation

Small for gestational age (SGA) newborns are at risk of hypoglycemia due to decreased glycogen stores and limited fat reserves. Therefore, monitoring blood glucose levels is essential to detect and promptly intervene in case of hypoglycemia.

A, B, C- monitoring other parameters such as vital signs, axillary temperature and weight are important aspects of newborn care but not specific to SGA newborns.

Correct Answer is []

Explanation

1. Potential Condition:

Hypoglycemia: The newborn is jittery and has decreased muscle tone, which are common signs of hypoglycemia (low blood sugar), especially in a newborn large for gestational age.

2. Actions to Take:

Check the newborn's capillary blood glucose level: This is crucial to confirm if hypoglycemia is the issue and to determine the appropriate treatment.
Place the newborn under a radiant warmer: This action helps stabilize the newborn’s body temperature, which is important as hypoglycemia can sometimes be associated with temperature instability.

3. Parameters to Monitor:

Temperature: Monitoring the temperature is important to ensure the newborn maintains normal body temperature and to identify any possible hypothermia.
Seizure activity: Jitteriness can sometimes progress to seizures if hypoglycemia is severe, so monitoring for seizure activity is critical.

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A nurse is assessing a client who is 4 hr postpartum following a vaginal delivery. Which of the following findings should the nurse identify as the priority?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is planning care for a newborn who is small for gestational age (SGA). Which of the following is the priority intervention the nurse should include in the newborn's plan of care?

Correct Answer is D

Explanation

A nurse is caring for a newborn. Exhibits Complete the diagram by specifying: The potential condition the newborn is most likely experiencing. Two actions the nurse should take to address that condition. Two parameters the nurse should monitor to assess the newborn's progress.

Correct Answer is []

Explanation

1. Potential Condition:

2. Actions to Take:

3. Parameters to Monitor:

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