A nurse is caring for a client who is at 40 weeks of gestation and is in labor. The client's ultrasound examination indicates that the fetus is small for gestational age (SGA). Which of the following interventions should be included in the newborn's plan of care?

Identify manifestations of anemia.

Monitor for hyperglycemia.

Observe for meconium in respiratory secretions.

Monitor for hyperthermia

Answer and Explanation

The Correct Answer is C

Rationale: A) Identify manifestations of anemia: While anemia can occur in newborns, especially in premature infants or those with specific maternal conditions, it is not necessarily a primary concern for infants who are small for gestational age (SGA). SGA infants are more at risk for issues related to intrauterine growth restriction (IUGR) and complications such as meconium aspiration syndrome (MAS) due to fetal distress, rather than anemia.

B) Monitor for hyperglycemia: SGA infants are at higher risk for hypoglycemia rather than hyperglycemia, particularly due to limited glycogen stores and increased metabolic demands after birth. Therefore, monitoring for and managing hypoglycemia is a more pertinent intervention for SGA newborns than monitoring for hyperglycemia.

C) Observe for meconium in respiratory secretions: SGA infants, who are born below the 10th percentile for their gestational age, are at increased risk for intrauterine hypoxia and stress, which can lead to meconium aspiration syndrome (MAS). Meconium aspiration occurs when the newborn inhales meconium-stained amniotic fluid, potentially causing airway obstruction and respiratory distress. Therefore, closely observing for meconium in respiratory secretions is crucial for timely intervention and management if MAS is suspected.

D) Monitor for hyperthermia: While hyperthermia can occur in newborns due to various reasons, including environmental factors and infection, it is not specifically associated with being born small for gestational age. Monitoring for hyperthermia is important in all newborns, but it is not a primary concern specifically related to SGA infants.

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Correct Answer is B

Explanation

A. Nonstress test is reactive: A reactive nonstress test indicates that the fetus is getting enough oxygen, which is a good sign, but it does not specifically indicate lung maturity.

B. Lecithin-sphingomyelin (L/S) ratio of 2:1: This is the correct answer. An L/S ratio of 2:1 or greater is a good indicator of fetal lung maturity. Lecithin and sphingomyelin are both types of phospholipids that make up surfactant, a substance that helps the lungs expand and prevents them from collapsing. As the fetal lungs mature, the amount of lecithin increases while the amount of sphingomyelin stays the same, leading to an increased L/S ratio.

C. Phosphatidylglycerol (PC) absent: The presence of phosphatidylglycerol (not its absence) in amniotic fluid is another indicator of lung maturity. It usually appears in significant amounts about the 35th week of gestation.

D. Biophysical profile score of 8: A biophysical profile score assesses the health of the fetus by looking at fetal heart rate, muscle tone, movement, breathing, and the amount of amniotic fluid. While a score of 8 out of 10 is generally considered good, it does not specifically indicate lung maturity.

A. Cracked, peeling skin B. Short soft fingernail C. Primitive Moro reflexes D. Abundant lanugo E. Vernix caseosa

Correct Answer is ["A"]

Explanation

A. Cracked, peeling skin: This is correct. Postmature newborns have often lost the protective vernix caseosa, and their skin may be dry and cracked as a result.

B. Short soft fingernails: This is not correct. Postmature newborns often have long fingernails.

C. Primitive Moro reflexes: This is not correct. The Moro reflex is a normal reflex for newborns and is not specifically associated with post maturity.

D. Abundant lanugo: This is not correct. Lanugo, the fine hair that covers the body of the fetus, is usually shed before birth. Postmature newborns have often lost most of their lanugo.

E. Vernix caseosa: This is not correct. Vernix caseosa, the white, cheesy substance that covers the skin of the fetus, is usually lost before birth in postmature newborns. As a result, their skin may be dry and cracked.

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A nurse is caring for a client who is at 40 weeks of gestation and is in labor. The client's ultrasound examination indicates that the fetus is small for gestational age (SGA). Which of the following interventions should be included in the newborn's plan of care?

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