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
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
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Place the client in knee chest position: This is the correct answer. If the nurse observes a prolapsed umbilical cord (the cord coming out before the baby), the first action should be to position the mother to relieve pressure on the cord. The knee-chest position can help achieve this.
B. Cover the cord with a sterile moist saline dressing: This action is important but not the first thing the nurse should do. The priority is to relieve pressure on the cord to prevent cord compression and subsequent fetal hypoxia.
C. Insert a gloved hand into the vagina to relieve pressure on the cord: This action may be necessary in some cases, but it is not the first action. The initial response should be to change the mother’s position to relieve pressure on the cord.
D. Prepare the client for an immediate birth: While an immediate birth may be necessary in the case of a prolapsed umbilical cord, the first action should be to relieve pressure on the cord to prevent fetal hypoxia. Preparations for an immediate birth would follow after initial interventions.
Correct Answer is A
Explanation
A. Report of headache: This is the correct choice. A headache is a common symptom of severe preeclampsia. It is often described as being very severe, and may be accompanied by changes in vision.
B. Tachycardia: This is not a typical finding in preeclampsia. While some women with severe preeclampsia may experience tachycardia, it is not a defining characteristic of the condition.
C. Polyuria: This is not typically associated with preeclampsia. In fact, decreased urine output (oliguria) may occur in severe cases due to the effect of preeclampsia on the kidneys.
D. Absence of clonus: This is not an expected finding. The presence of clonus, not its absence, might be an indication of severe preeclampsia. Clonus is a series of involuntary muscular contractions due to sudden stretching. It can be seen in severe cases of preeclampsia, indicating potential neurological involvement. However, its absence does not rule out preeclampsia.
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