A nurse is caring for a newborn who was born at 39 weeks gestation and weighs 3350 g. Based on the weight and gestational age, what is the most appropriate way to document the findings?

Small for gestational age (SGA).

Appropriate (average) for gestational age (AGA).

Low birth weight.

Large for gestational age (LGA).

Answer and Explanation

The Correct Answer is B

Choice A rationale

Small for gestational age (SGA) refers to newborns whose birth weight is below the 10th percentile for their gestational age.

Choice B rationale

Appropriate for gestational age (AGA) refers to newborns whose birth weight is between the 10th and 90th percentiles for their gestational age. A newborn weighing 3350 g at 39 weeks gestation falls within this range.

Choice C rationale

Low birth weight is defined as a birth weight of less than 2500 g, which does not apply to this newborn.

Choice D rationale

Large for gestational age (LGA) refers to newborns whose birth weight is above the 90th percentile for their gestational age.

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Correct Answer is D

Explanation

Choice A rationale

Stretching arms out and then back in is a common reflex in newborns known as the Moro reflex. It is not a sign of feeding readiness but rather a response to a sudden loss of support or a loud noise.

Choice B rationale

Turning the head toward a parent’s voice is a sign of auditory recognition and bonding, not necessarily feeding readiness. It indicates the infant’s ability to recognize familiar sounds.

Choice C rationale

Grasping a parent’s finger when placed in the infant’s palm is a primitive reflex known as the palmar grasp reflex. It is not related to feeding readiness but is a normal reflexive action in newborns.

Choice D rationale

Bringing their hand to their mouth is a sign of feeding readiness. This action indicates that the infant is hungry and ready to feed. It is an early cue that the baby is ready to eat.

A. Administer a bolus of intravenous glucose. B. Reassess the neonate’s blood glucose level in 30 minutes. C. Initiate feeding with formula or breast milk. D. Place the neonate under a radiant warmer.

Correct Answer is A

Explanation

Choice A rationale

Given the neonate’s symptoms and critically low blood glucose level (30 mg/dL), the most urgent action is to address the hypoglycemia. Therefore, the nurse shouldadminister a bolus of intravenous glucose (Option A). This immediate intervention is crucial to stabilize the neonate and prevent further complications associated with hypoglycemia.

Choice B rationale

While monitoring blood glucose levels is important, waiting 30 minutes to reassess without immediate intervention could allow the hypoglycemia to worsen, potentially leading to severe complications such as seizures or brain damage. Immediate treatment is necessary to stabilize the neonate..

Choice C rationale

Although feeding can help increase blood glucose levels, the neonate’s current symptoms (jitteriness, poor feeding, weak cry, and irritability) suggest that they may not be able to effectively feed. Additionally, the blood glucose level is critically low and requires more rapid correction than feeding alone can provide..

Choice D rationale

While maintaining an appropriate body temperature is important, the neonate’s temperature (36.1°C) is not critically low. The primary concern here is the hypoglycemia, which needs to be addressed immediately. Placing the neonate under a radiant warmer does not directly address the low blood glucose level..

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A nurse is caring for a newborn who was born at 39 weeks gestation and weighs 3350 g. Based on the weight and gestational age, what is the most appropriate way to document the findings?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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