A macrosomic infant is born after a difficult forceps-assisted delivery. After stabilization, the infant is weighed, and the birth weight is 4550 g (9 pounds, 6 ounces). The nurse's most ap-propriate action is to:

Question

1. leave the infant in the room with the mother.
2. take the infant immediately to the nursery.
3. perform a gestational age assessment to determine if the infant is large for gesta-tional age.
4. monitor blood glucose levels frequently, and observe closely for signs of hypog-lycemia.

Answer 1

4
1. Incorrect. Macrosomic infants are at high risk for hypoglycemia after birth and need to be closely observed. This can be achieved in the mother's room with nursing interventions, de-pending on the condition of the fetus. It may be more appropriate for observation to occur in the nursery.
2. Incorrect. Macrosomic infants are at high risk for hypoglycemia after birth and need to be closely observed. Observation may occur in the nursery or in the mother's room, depending on the condition of the infant.
3. Incorrect. Regardless of gestational age, this infant is macrosomic. Macrosomia is defined as fetal weight greater than 4000 g. Hypoglycemia affects many macrosomic infants. Blood glucose levels should be closely observed.
4. Correct. This infant is macrosomic (more than 4000 g) and is at high risk for hypogly-cemia. Blood glucose levels should be monitored frequently, and the infant should be closely observed for signs of hypoglycemia.