A nurse is caring for a newborn who is large for gestational age and is 12 hr old. Which of the following laboratory tests should the nurse monitor for based on the client's condition?

Bilirubin

Glucose

Arterial blood gases

WBC count

Answer and Explanation

The Correct Answer is B

A. While bilirubin levels are important, the immediate concern for a large-for-gestational-age (LGA) newborn is hypoglycemia.
B. LGA newborns are at increased risk for hypoglycemia, so monitoring blood glucose levels is essential.
C. Arterial blood gases are not routinely indicated unless respiratory distress is present.
D. WBC count is not specifically related to LGA status.

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Correct Answer is C

Explanation

A. Changing a perineal pad every 4 hours is within expected postpartum norms for moderate bleeding. This client’s condition does not indicate an urgent issue.

B. A urine output of 750 mL over 6 hours is adequate (approximately 125 mL/hr) and does not signal immediate concern.

C. Deep tendon reflexes of 1+ in a client receiving IV magnesium sulfate may indicate early magnesium toxicity or impending hyporeflexia. Magnesium sulfate toxicity can lead to respiratory depression and cardiac arrest, making this the highest-priority client.

D. Abdominal cramping during breastfeeding is common due to uterine contractions (afterpains) and is generally expected and non-life-threatening. This can be addressed after assessing higher-priority clients.

A. Soft abdomen B. Heart rate 120/min C. A fetal heart of 150/min with moderate variability D. Painless vaginal bleeding

Correct Answer is B

Explanation

A. A grade 2 placental abruption typically presents with a firm or rigid abdomen due to concealed bleeding, not a soft one.
B. Maternal tachycardia (heart rate 120/min) is expected due to blood loss and compensatory response to hypovolemia.
C. A fetal heart rate of 150/min with moderate variability is a reassuring sign and would not typically be expected in a significant abruption, where fetal distress is more common.
D. Vaginal bleeding from placental abruption is typically painful, and may be concealed. Painless bleeding is more characteristic of placenta previa.

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A nurse is caring for a newborn who is large for gestational age and is 12 hr old. Which of the following laboratory tests should the nurse monitor for based on the client's condition?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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