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.

Nursing Test Bank

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

Correct Answer is D

Explanation

A. Headache for 30 min: While a headache can be a side effect of magnesium sulfate, it is not typically a critical concern that needs to be reported immediately. However, persistent or severe headaches should be reported.

B. Fetal heart rate 158/min: This is within the normal range for a fetal heart rate (110-160 beats per minute), so it would not typically need to be reported.

C. Respirations 16/min: This is within the normal range for adult respiratory rate (12-20 breaths per minute), so it would not typically need to be reported.

D. Urinary output 40 mL in 2 hours: This is the correct answer. A urinary output of less than 30 mL/hr. may indicate renal insufficiency, which can be a serious side effect of magnesium sulfate therapy. This should be reported to the provider immediately.

A. Promote delivery of the placenta. B. Prevent the perineum from tearing C. Apply perineal pressure to the emerging fetal head. D. Cut the umbilical cord.

Correct Answer is C

Explanation

A. Promote delivery of the placenta: This is not the priority action. The delivery of the placenta occurs after the birth of the baby, not during the active labor phase.
B. Prevent the perineum from tearing: While preventing perineal tearing is important, it is not the priority action. The nurse can help prevent tearing by providing perineal support during the delivery, but the immediate priority is to manage the rapidly progressing labor.
C. Apply perineal pressure to the emerging fetal head: This is the correct choice. In a rapidly progressing labor, the priority is to prevent an uncontrolled delivery and potential injury to the baby. Applying gentle pressure to the perineum and the emerging fetal head can help control the delivery.
D. Cut the umbilical cord: This is not the priority action. The umbilical cord is cut after the baby is born, not during the active labor phase. It’s also important to note that cutting the umbilical cord is usually performed by the healthcare provider, not the nurse.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is assessing a client who is receiving magnesium sulfate to treat a suspected placenta previa. Which of the following findings must the nurse report to the provider?

Correct Answer is D

Explanation

A nurse is caring for a client who presents to a labor and delivery unit experiencing rapidly progressing labor. Which of the following is the priority action for the nurse to take?

Correct Answer is C

Explanation

A nurse is caring for a client who is to undergo an amniotomy. Which of the following is the priority nursing action following this procedure?

A nurse is caring for a client who is in active labor with 7 cm of cervical dilation and 100% effacement. The fetus is at 1+ station, and the client's amniotic membranes are intact. The client suddenly states that she needs to push Which of the following actions should the nurse take?

A nurse is caring for a client who is at 40 weeks gestation and is in active labor. The client has 6 cm of cervical dilation and 100% cervical effacement. The nurse obtains the client's blood pressure reading as 82/52 mm Hg. Which of the following nursing interventions should the nurse perform?

A nurse is caring for a new mother who is concerned that her newborns eyes cross. Which of the following statements is a therapeutic response by the nurse?

A nurse is assessing a client who received magnesium sulfate to treat preterm labor. Which of the following clinical findings should the nurse identify as an indication of toxicity of magnesium sulfate therapy and report to the provider?

A nurse is caring for a client who is in labor and has an epidural anesthesia block. The client’s blood pressure is 80/40mmHg and the fetal heart rate is 140/min. Which of the following is the priority nursing action?

A nurse is completing discharge instructions for a new mother and her 2-day-old newborn. The mother asks "How will I know if my baby gets enough breast milk? Which of the following responses should the nurse make?