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.

Answer and Explanation

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

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Correct Answer is C

Explanation

The correct answer is choiceC. Respiratory rate.

Choice A rationale:

Monitoring the fetal heart rate (FHR) is crucial during labor to assess the well-being of the fetus.However, when administering magnesium sulfate, the primary concern is the mother’s respiratory status due to the risk of respiratory depression, which can be a side effect of the medication.

Choice B rationale:

While bowel sounds are an important part of a comprehensive assessment, they are not the primary concern when administering magnesium sulfate.Magnesium sulfate primarily affects the neuromuscular and respiratory systems.

Choice C rationale:

Respiratory rate is the primary nursing assessment for a client receiving magnesium sulfate IV.Magnesium sulfate can cause respiratory depression, so it is essential to monitor the client’s respiratory status closely to detect any signs of respiratory compromise early.

Choice D rationale:

Monitoring temperature is important in any clinical setting, but it is not the primary concern when administering magnesium sulfate.The primary focus should be on the respiratory rate due to the potential for respiratory depression.

A. “I will call your primary care provider to report your concerns.”. B. “This is a concern, but strabismus is easily treated with patching.”. C. “This occurs because newborns lack muscle control to regulate eye movement.”. D. “I will take your baby to the nursery for further examination.”. .

Correct Answer is C

Explanation

Choice A rationale
While it’s important to report concerns to the primary care provider, this does not directly address the mother’s concern about her newborn’s crossed eyes.
Choice B rationale
Strabismus is a condition where the eyes do not properly align with each other, but it is not the same as the normal crossing of a newborn’s eyes.
Choice C rationale
This is the correct answer. Newborns often lack the muscle control to regulate eye movement, which can cause their eyes to cross.
Choice D rationale
Taking the baby to the nursery for further examination may be necessary if there are other concerns, but it does not directly address the mother’s concern about her newborn’s crossed eyes.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is preparing to administer magnesium sulfate IV to a client who is in labor. Which of the following is the primary nursing assessment for this client?

Correct Answer is C

Explanation

A nurse is caring for a new mother who is worried about her newborn’s crossed eyes. Which of the following responses by the nurse would be therapeutic?

Correct Answer is C

Explanation

Which of the following provider prescriptions should the nurse plan to implement? Select the 3 actions the nurse should plan to take. Exhibits here Exhibits Which of the following provider prescriptions should the nurse plan to implement? Select the 3 actions the nurse should plan to take.

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