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. "Have you spoken to your mother about these feelings’’: While family support can be helpful, it’s not the nurse’s place to suggest who the client should talk to about her feelings. Each person’s support system is unique and personal.

B. "Perhaps you should see a counsellor to discuss these feelings further”: While professional help can be beneficial, suggesting it as the first response may make the client feel that her feelings are abnormal or something to be concerned about.

C. "Ambivalent feelings are quite common for women early in pregnancy”: This is the correct choice. It’s important to normalize the client’s feelings. Pregnancy, especially the first one, is a significant life event filled with changes. It’s completely normal to have mixed feelings and doubts.

D. “Don’t worry. You will be fine once the baby is born”: This response dismisses the client’s feelings and concerns. It’s important to validate the client’s feelings rather than minimizing them. Every person’s experience with pregnancy and parenthood is unique, and it’s not helpful to make assumptions about how the client will feel in the future.

A. The client's blood does not contain the Rh factor so she produces anti- Rh antibodies that cross the placenta barrier and cause hemolysis of red blood cells in newborns. B. The client's anti-A and ant-B antibodies cross the placenta and cause the destruction of the fetal red blood cells C. The client's blood contains the Rh factor and the newborns does not, and antibodies that destroy the red blood cells are formed in the fetus D. The client has a history of receiving a transfusion with Rh-negative blood

Correct Answer is A

Explanation

A. The client’s blood does not contain the Rh factor so she produces anti- Rh antibodies that cross the placenta barrier and cause hemolysis of red blood cells in newborns: This is the correct answer. If the mother is Rh-negative and the baby is Rh-positive, the mother’s body may produce antibodies against the baby’s blood. These antibodies can cross the placenta and cause hemolysis (destruction) of the baby’s red blood cells, leading to hyperbilirubinemia.

B. The client’s anti-A and ant-B antibodies cross the placenta and cause the destruction of the fetal red blood cells: This is not correct. Anti-A and anti-B antibodies are related to the ABO blood group system, not the Rh system.

C. The client’s blood contains the Rh factor and the newborns does not, and antibodies that destroy the red blood cells are formed in the fetus: This is not correct. It is when the mother is Rh-negative and the baby is Rh-positive that there is a risk of Rh incompatibility.

D. The client has a history of receiving a transfusion with Rh-negative blood: This is not correct. A history of receiving a transfusion with Rh-negative blood would not cause Rh incompatibility in a subsequent pregnancy. Rh incompatibility is caused by a difference in Rh factor between the mother and baby.

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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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Naxlex Comprehensive Predictor Exams

Correct Answer is C

Explanation

A nurse is caring for a client who has just delivered her first newborn. The nurse anticipates hyperbilirubinemia due to Rh incompatibility. The nurse should understand that hyperbilirubinemia occurs with Rh incompatibility for which of the following reasons?

Correct Answer is A

Explanation

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