The nurse is planning care for a newborn client at term gestation who is large for gestational age. Which of the following are appropriate interventions to include in the plan of care? Select all that apply.

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NCLEX® CHANGE AS OF 2017 - Please note that select-all-that-apply (SATA) questions on NCLEX can now include any number of correct responses. Only ONE option or up to ALL options may be correct. UWorld questions now reflect this change. Visit NCSBN® NCLEX FAQs for more information. Newborns who are large for gestational age (LGA) are diagnosed after birth by plotting their birth weight and gestational age on a growth chart; weight must be at least >90th percentile and is commonly >8 lb 13oz (4000 g). Risk factors include gestational diabetes; excessive gestational weight gain or elevated prepregnancy BMI; history of a prior newborn who was LGA; postterm gestation; and genetics (eg, male sex, maternal birth weight, ethnicity). The nurse should prioritize assessment of birth injuries and hypoglycemia. When developing the plan of care for a newborn who is LGA, the nurse should include the following interventions: Document gestational age assessment, weight, length, and head circumference to identify newborns who are LGA. Assess the newborn for birth-related injuries (eg, cephalohematoma, clavicular fracture, lacerations) and review the birth record to determine if an operative vaginal birth occurred (eg, forceps) (Option A). Discuss the need for possible feeding supplementation (eg, breastmilk, formula) if the newborn is hypoglycemic (Option B). Assist the mother to feed the newborn soon after birth and every 2-3 hours thereafter to prevent hypoglycemia (Option C). Obtain a capillary blood glucose (BG) before feeding to assess for hypoglycemia, and notify the health care provider when a capillary BG reading is <40-45 mg/dL (2.2-2.5 mmol/L) (Options D and E). Educational objective: Newborns who are large for gestational age have a birth weight that is >90th percentile. The nurse should create a plan of care for the newborn that prioritizes assessment of birth injuries and hypoglycemia in addition to routine newborn care.

The Nurse Is Planning Care for a Newborn Client at Term