Today’s NCLEX-RN® question of the day focuses on assessment findings in small for gestational age (SGA) newborns.
Which assessment finding(s) in a 36-weeks gestation newborn weighing 2000g during the first hour of life requires follow-up by the nurse? Select all that apply.
A. Respirations 60/minute
B. Temperature (axillary) 96 F (35.5 C)
C. Heart rate: 150/min
D. Capillary blood glucose 40 mg/dL
E. Bluish discoloration of the hands and feet
F. Transcutaneous bilirubin 5 mg/dL
Scroll down for the correct answer!
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The correct answers to today’s NCLEX-RN® Question are…
B. Temperature (axillary) 96 F (35.5 C)
D. Capillary blood glucose 40 mg/dL
F. Transcutaneous bilirubin 5 mg/dL
Rationale: An infant born at 36 weeks of gestation and weighing 2000g is smaller than normal for their gestational age, or SGA. Newborns who are SGA are at risk for temperature instability, hypoglycemia (low blood glucose), and hyperbilirubinemia (high bilirubin) related to polycythemia (increased number of red blood cells). The nurse should recognize the newborn’s temperature, glucose, and transcutaneous bilirubin levels as abnormal, and should follow-up right away. Normal assessments include the respiratory rate (normal range is 30-60/min), heart rate (normal range 120-160/min), and the bluish discoloration of the hands and feet, called acrocyanosis (caused by vasomotor instability, and is normal in newborns during the first 24 hours of life).
Main takeaway
The nurse should recognize the SGA newborn is at risk for problems such as temperature instability, hypoglycemia, and hyperbilirubinemia and should intervene when these assessments are not within normal limits.
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