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 C

Explanation

A. Assist the client into a comfortable position: While comfort is important during labor, it is not the priority in this situation. The client is not yet fully dilated and should not start pushing yet.

B. Help the client to the bathroom to void: This is not the priority at this time. The client is in active labor and should not be moved unnecessarily.

C. Have the client pant during the next contractions: This is the correct answer. Panting can help to resist the urge to push until the cervix is fully dilated to 10 cm. Pushing before full dilation can lead to cervical edema and prolong the labor process.

D. Observe the perineum for signs of crowning: While this will be important as the client gets closer to delivery, it is not the priority at this time. The client is not yet fully dilated and should not start pushing yet.

A. Amniotic fluid volume B. Fetal motion C. Fetal breathing D. Fetal gender E. Fetal neck translucency

Correct Answer is ["A","B","C"]

Explanation

A. Amniotic fluid volume: This is correct. The biophysical profile evaluates the volume of amniotic fluid, which can provide information about the health of the fetus and the placenta.
B. Fetal motion: This is correct. The biophysical profile assesses fetal motion, including gross body movements and fetal tone (flexion and extension of extremities).
C. Fetal breathing: This is correct. The biophysical profile includes an assessment of fetal breathing movements, which are a sign of fetal well-being.
D. Fetal gender: This is not correct. The biophysical profile does not evaluate the gender of the fetus. The gender can be determined through other ultrasound examinations, but it is not part of the biophysical profile.
E. Fetal neck translucency: This is not correct. Fetal neck translucency is assessed during a specific type of ultrasound examination performed in the first trimester to screen for chromosomal abnormalities, not during a biophysical profile. The biophysical profile is typically performed in the third trimester to assess fetal well-being.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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?

Correct Answer is C

Explanation

A nurse is caring for a client who is to undergo a biophysical profile. The client asks the nurse what is being evaluated during this test. Which of the following should the nurse include? (Select all that apply.)

Correct Answer is ["A","B","C"]

Explanation

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