A nurse is caring for a newborn who is large for gestational age and is 12 hours old.
Which of the following laboratory tests should the nurse monitor based on the client's condition?
Bilirubin.
Glucose.
White blood cell count.
Arterial blood gases.
The Correct Answer is B
Choice A rationale
Bilirubin monitoring is critical for jaundice due to hemolysis, often seen in ABO incompatibility or cephalohematoma. While Large for Gestational Age (LGA) infants can have polycythemia, hypoglycemia is a more immediate and life-threatening risk that requires priority monitoring in the first hours of life. The normal total bilirubin range is typically less than 5 mg/dL in the first 24 hours.
Choice B rationale
LGA infants are often born to mothers with uncontrolled or gestational diabetes, leading to fetal hyperinsulinism. After birth, the maternal glucose supply is cut off, and the high insulin levels persist, causing a rapid and profound drop in the newborn's blood glucose, hence hypoglycemia is a major concern. The normal newborn glucose range is 40 to 60 mg/dL and should be monitored.
Choice C rationale
White blood cell (WBC) count is primarily monitored to detect neonatal sepsis or infection. While all newborns are at risk, the LGA classification does not inherently place them at a higher, unique risk for infection compared to the immediate metabolic derangement risks like hypoglycemia. The normal WBC count range is 9,000 to 30,000 cells/mm.
Choice D rationale
Arterial Blood Gases (ABGs) are used to assess the newborn's respiratory status and acid-base balance, particularly in respiratory distress syndrome or persistent pulmonary hypertension. While LGA infants can experience birth trauma or meconium aspiration, ABG monitoring is not routine unless significant respiratory symptoms are present.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A rationale
A transvaginal fetal Doppler probe is an internal device used early in pregnancy to confirm fetal viability or heart rate in the first trimester, not an appropriate method for continuous intrapartum monitoring in a full-term client with intact membranes.
Choice B rationale
The DeLee-Hillis fetoscope is an external acoustic device used for intermittent auscultation of the fetal heart rate, providing a listening assessment rather than the prescribed continuous electronic tracing required for this client.
Choice C rationale
An external ultrasound transducer monitor (or tocodynamometer for contractions) uses non-invasive Doppler technology placed on the client's abdomen to detect and continuously monitor the fetal heart rate and uterine contractions when membranes are intact, satisfying the continuous monitoring prescription without internal access.
Choice D rationale
An internal fetal scalp electrode (FSE) requires the rupture of membranes and sufficient cervical dilation for placement onto the fetal scalp to provide a precise electrocardiogram of the fetal heart, which is not applicable since the client's membranes are intact.
Correct Answer is ["B","C","D"]
Explanation
Choice A rationale
Consistent crying is considered a late cue of hunger in a newborn. Crying, a complex physiological and behavioral response, requires a high expenditure of energy and is an indication that the newborn is already significantly distressed by hunger and needs to be fed immediately to avoid excessive agitation and difficulty latching.
Choice B rationale
The rooting reflex involves the newborn turning their head toward any stimulation of their cheek or mouth and opening their mouth, which is an innate physiological response critical for locating the nipple. This is a primary early hunger cue, indicating the newborn is ready and searching for a food source, initiating feeding efforts.
Choice C rationale
Sucking motions, such as rapid, repetitive sucking on the lips, tongue, or anything near the mouth, are direct early behavioral manifestations of the newborn's innate physiological need for nourishment. This action is a preparatory step for feeding, indicating readiness for oral intake and satiation of hunger.
Choice D rationale
Hand-to-mouth movements are a key early hunger cue, demonstrating the newborn's increasing drive to seek oral stimulation and food. This behavior is part of the newborn's reflexive self-soothing and exploratory repertoire, signaling a rising level of hunger before the onset of overt distress or crying.
Choice E rationale
The Babinski reflex is a normal neurological response in infants where the great toe extends upward and the other toes fan out when the sole of the foot is firmly stroked. It is a primitive reflex related to neurological development and is not an indicator of hunger or feeding readiness.
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