A nurse is formulating a care plan for a newborn who is small for gestational age (SGA). Which of the following should be the priority intervention in the newborn’s care plan?
Monitor weight.
Monitor I&O.
Monitor axillary temperature.
Monitor blood glucose levels.
The Correct Answer is D
Choice A rationale
Monitoring weight is important for a newborn who is small for gestational age (SGA), but it is not the priority intervention. Weight can provide information about the newborn’s growth and development, but it does not address immediate physiological needs.
Choice B rationale
Monitoring I&O (Intake and Output) is crucial in assessing the newborn’s hydration status and kidney function. However, it is not the priority intervention for an SGA newborn.
Choice C rationale
Monitoring axillary temperature is important to maintain the newborn’s thermal regulation. However, it is not the priority intervention. Newborns, especially those who are SGA, are at risk for hypothermia due to their high body surface area to volume ratio and lack of subcutaneous fat.
Choice D rationale
Monitoring blood glucose levels is the priority intervention for an SGA newborn. SGA newborns are at risk for hypoglycemia because they have fewer glycogen stores. Hypoglycemia can lead to serious complications such as seizures, hence the need for close monitoring
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale
Repaglinide is an oral medication used to control blood sugar in people with type 2 diabetes, but it is not typically used in pregnancy.
Choice B rationale
Insulin is the most common medication used to control blood sugar in pregnant women with gestational diabetes when diet and exercise are not enough.
Choice C rationale
Acarbose is an oral medication used to control blood sugar in people with type 2 diabetes, but it is not typically used in pregnancy.
Choice D rationale
Glipizide is an oral medication used to control blood sugar in people with type 2 diabetes, but it is not typically used in pregnancy.
Correct Answer is A
Explanation
Choice A rationale
Late decelerations on the fetal monitor are a sign of fetal hypoxia, which means the baby is not getting enough oxygen. The priority nursing action is to position the client on her side, preferably the left side. This position improves blood flow to the uterus and the baby, potentially improving oxygenation.
Choice B rationale
Administering oxygen via face mask can also improve fetal oxygenation, but it is not the first action the nurse should take. Repositioning the client is a quicker intervention and often resolves the issue.
Choice C rationale
Elevating the client’s legs will not improve fetal oxygenation and is not a priority action when late decelerations are noted on the fetal monitor.
Choice D rationale
Increasing the infusion rate of the IV fluid can improve maternal blood volume and cardiac output, potentially improving blood flow to the uterus and the baby. However, it is not the first action the nurse should take when late decelerations are noted.
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