Large for Gestational Age (LGA) Practice Exam

EXPLANATION

✔Correct answer:

Term, small for gestational age, and low-birth-weight. The newborn is classified as "term" because she was delivered at 38 weeks of gestation. Infants born between 37 and 42 weeks are considered term. Given her weight of 2000 g, which places her below the 10th percentile for weight, the infant is also classified as "small for gestational age (SGA)." Additionally, the term "low-birth-weight" (LBW) refers to infants who weigh less than 2500 g at birth. Thus, this newborn fits all these classifications: term, SGA, and low-birth-weight.

Classifications Explained:

• Term: Infants born between 37 and 42 weeks of gestation.
• Small for Gestational Age (SGA): Infants whose birth weight is below the 10th percentile for their gestational age.
• Low-Birth-Weight (LBW): Infants weighing less than 2500 g, regardless of gestational age.

Imagine gestational age and weight as similar to a tree's growth. A tree (the baby) that reaches a certain age (weeks of gestation) is expected to be a certain height (weight). If the tree is smaller than expected for its age, it would be considered 'small for its age.' Similarly, if the tree weighs less than a certain threshold (2500 g), it would be 'low weight.'

Understanding these classifications helps guide care planning for the infant. SGA and LBW infants are at higher risk for complications such as hypoglycemia, temperature instability, and respiratory issues. Nurses should:

• Monitor the infant's glucose levels and initiate early feedings to prevent hypoglycemia.
• Ensure the infant is kept warm to maintain body temperature, possibly using skin-to-skin contact or an incubator.
• Assess for respiratory distress and provide respiratory support if needed.
• Educate the parents on the importance of frequent feeding and close monitoring of the infant’s growth.

✘Incorrect answer options:

Term, small for gestational age, and very-low-birth-weight. While the newborn is correctly classified as "term" and "small for gestational age," the classification of "very-low-birth-weight" (VLBW) is inaccurate. VLBW refers to infants weighing less than 1500 g, whereas this infant weighs 2000 g.

Late preterm, appropriate for gestational age. The term "late preterm" refers to infants born between 34 and 36 weeks of gestation, which does not apply to this infant born at 38 weeks. Additionally, the infant is classified as "small for gestational age," not "appropriate for gestational age."

Late preterm, large for gestational age, and low-birth-weight. This option is incorrect on multiple accounts. The infant is "term," not "late preterm," "small for gestational age," not "large for gestational age," and the "low-birth-weight" classification is accurate, but the other two aspects are incorrect.

EXPLANATION

✔Correct answer:

Maternal diabetes. The condition most commonly linked to a newborn being large-for-gestational-age (LGA) or macrosomic is maternal diabetes. This includes both gestational diabetes and pre-existing diabetes (type 1 or type 2). When a mother has diabetes, elevated blood glucose levels cross the placenta and reach the fetus. The fetus responds by producing more insulin, a hormone that promotes the storage of fat and growth, leading to increased fetal size and weight. This condition is known as macrosomia, where the fetus grows larger than normal for its gestational age.

Maternal hyperglycemia (high blood sugar) results in excess glucose being transferred to the fetus, leading to fetal hyperinsulinemia (excess insulin production). The increased insulin acts as a growth hormone, contributing to excessive fetal growth and fat deposition, resulting in a macrosomic infant.

Think of the mother's body like a garden with an automatic watering system (blood glucose levels). If the system provides too much water (glucose), the plants (the fetus) grow much larger than normal because they are being over-nourished, leading to oversized plants (macrosomic baby).

Recognizing the link between maternal diabetes and fetal macrosomia is crucial for proper management during pregnancy and delivery. Macrosomic infants are at higher risk for complications such as birth injuries (e.g., shoulder dystocia), hypoglycemia, and respiratory distress after birth. Therefore, careful monitoring and planning are required.

• Monitor the infant's blood glucose levels closely after birth to detect and treat hypoglycemia.
• Assess the infant for signs of birth trauma, such as shoulder dystocia, clavicle fractures, or brachial plexus injury.
• Collaborate with the healthcare team to manage the delivery process to minimize the risk of injury during birth.
• Educate the mother about the importance of controlling blood glucose levels during pregnancy to reduce the risk of macrosomia.
• Encourage early and frequent breastfeeding or feeding to maintain stable glucose levels in the newborn.

✘Incorrect answer options:

Maternal celiac disease. Maternal celiac disease, which is an autoimmune disorder affecting the small intestine's ability to absorb nutrients, is typically associated with low birth weight or intrauterine growth restriction (IUGR), not macrosomia. Poor nutrient absorption may hinder fetal growth.

Maternal alcohol consumption. Maternal alcohol consumption is linked to fetal alcohol spectrum disorders (FASDs), which are associated with growth restriction, developmental delays, and various physical anomalies. It does not lead to an increased birth weight or LGA.

Maternal hypertension. Maternal hypertension, particularly chronic hypertension or preeclampsia, is generally associated with intrauterine growth restriction (IUGR) due to compromised placental blood flow, leading to smaller infants. It is not typically linked to macrosomia.

EXPLANATION

✔Correct answer:

One of the newborn’s clavicles may have been fractured during delivery. The primary reason Nurse Taylor is palpating the neonate’s clavicles is to assess for any fractures, which can occur during delivery, especially in large-for-gestational-age (LGA) newborns. Infants born to mothers with diabetes are often larger, and due to their size, they are at increased risk of birth injuries such as shoulder dystocia. During a difficult delivery, particularly in cases of shoulder dystocia, excessive force or pressure may be applied to the baby's shoulders, potentially leading to a clavicle (collarbone) fracture.

Shoulder dystocia is a delivery complication where the baby’s shoulder gets stuck behind the mother’s pubic bone after the head has been delivered. The maneuvering required to safely deliver the baby in this situation can sometimes result in fractures, particularly of the clavicles.

Think of the clavicles like small tree branches. If too much force is applied while trying to move a large branch through a narrow space, the smaller branches might snap. In a similar way, the baby’s clavicle can fracture during a tough delivery process.

If a clavicle fracture is detected, it is important to handle the newborn carefully and provide appropriate support. Treatment typically involves immobilizing the affected area and ensuring pain relief.

• Gently handle the baby to avoid further injury.
• Provide pain management if the newborn shows signs of discomfort.
• Educate the parents on how to care for a newborn with a clavicle fracture, including proper positioning during feeding and handling.
• Monitor the newborn for any signs of complications, such as nerve damage or improper healing.

✘Incorrect answer options:

Clavicles are often absent in newborns of diabetic mothers. This statement is incorrect. The presence or absence of clavicles is not related to maternal diabetes. Clavicles are present in all healthy newborns.

Newborns of diabetic mothers tend to have brittle bones. While maternal diabetes can cause complications, it does not specifically cause the newborn to have brittle bones. The concern here is more about the risk of trauma during delivery rather than bone fragility.

LGA newborns can develop glucose deposits on their clavicles. This is incorrect. There is no physiological mechanism for glucose deposits to form on clavicles. The palpation of the clavicles is to check for fractures, not glucose deposits.

EXPLANATION

✔Correct answer:

Jitteriness and tremors. Jitteriness and tremors are common signs of hypoglycemia in newborns, particularly in those who are large-for-gestational-age (LGA). Hypoglycemia occurs when the blood glucose levels drop below normal, which can happen because LGA newborns, especially those born to mothers with diabetes, may produce excessive insulin in response to high blood glucose levels in utero. After birth, the sudden withdrawal of maternal glucose can lead to a rapid drop in the newborn's blood glucose levels, causing symptoms like jitteriness and tremors.

In utero, LGA infants may be exposed to higher levels of glucose from the mother, especially if she has diabetes. This causes the fetus to produce more insulin to manage the excess glucose. After birth, when the glucose supply is abruptly stopped, the infant's high insulin levels can cause blood glucose levels to fall too low, leading to hypoglycemia and associated symptoms like jitteriness.

Imagine the newborn’s blood sugar levels like a balloon that's been filled with too much air (insulin) while still attached to a pump (maternal glucose). As long as the pump is connected, the balloon stays inflated just right. But once the pump is suddenly disconnected (at birth), the balloon deflates too quickly, causing it to wobble and shake (jitteriness and tremors). This rapid drop represents the newborn's blood sugar levels falling too fast, leading to symptoms of hypoglycemia.

If jitteriness or tremors are observed, Nurse Simmons should promptly check the newborn's blood glucose levels. Early identification and treatment of hypoglycemia are crucial to prevent more severe complications, such as seizures or neurological damage.

• Monitor blood glucose levels regularly, especially within the first few hours of life.
• Administer oral or intravenous glucose as prescribed if hypoglycemia is confirmed.
• Encourage early and frequent feedings to maintain stable glucose levels.
• Observe the infant for other signs of hypoglycemia, including lethargy, poor feeding, and seizures.
• Document and report any abnormal findings to the healthcare provider immediately.

✘Incorrect answer options:

Frequent yawning. Frequent yawning is not typically associated with hypoglycemia. It may indicate fatigue or a response to other environmental stimuli, but it is not a reliable indicator of low blood glucose levels.

High-pitched cry. While a high-pitched cry can be a sign of various neonatal conditions, including central nervous system irritability or withdrawal symptoms, it is not specific to hypoglycemia. The most common early signs of hypoglycemia are jitteriness, tremors, and lethargy.

Flushed skin. Flushed skin is not a common symptom of hypoglycemia. Hypoglycemia more commonly presents with signs like pallor, cyanosis, or cold extremities rather than flushed skin.

EXPLANATION

✔Correct answer:

Hypoglycemic and large for gestational age. Newborns of mothers with diabetes are most commonly large for gestational age (LGA) due to the excess glucose they are exposed to in utero. The fetus’s pancreas responds to the high maternal blood glucose by producing more insulin, which promotes growth and fat deposition, leading to a larger size at birth. After delivery, the sudden removal of maternal glucose supply, combined with the high levels of insulin, can cause the newborn to experience hypoglycemia.

During pregnancy, maternal hyperglycemia leads to increased glucose transfer to the fetus. The fetus responds by increasing insulin production, which contributes to excessive growth (macrosomia). After birth, the infant's high insulin levels continue, but the glucose supply drops, resulting in hypoglycemia.

Imagine the baby as a car that’s been running on high fuel (glucose) during pregnancy because the mother’s body was constantly filling up the tank. The baby’s engine (insulin production) was revved up to burn all that extra fuel. Once the baby is born, the fuel supply suddenly stops, but the engine is still running fast. Without more fuel coming in, the car starts to sputter and slow down, which is like the baby’s blood sugar dropping quickly, leading to hypoglycemia.

Monitoring and managing hypoglycemia in LGA infants is critical to prevent complications such as seizures or neurological damage.

• Regularly monitor blood glucose levels in the newborn, especially within the first few hours after birth.
• Provide early and frequent feedings to help stabilize glucose levels.
• If hypoglycemia is detected, administer glucose supplements as per protocol.
• Educate parents on the importance of monitoring for signs of hypoglycemia and the need for follow-up care.

✘Incorrect answer options:

Hypoglycemic and small for gestational age. While hypoglycemia is common in infants of diabetic mothers, these infants are typically LGA rather than SGA due to the excess maternal glucose leading to increased fetal growth.

Hyperglycemic and large for gestational age. Newborns of diabetic mothers are not typically hyperglycemic after birth. Instead, they are at risk for hypoglycemia due to their elevated insulin levels in response to maternal hyperglycemia during pregnancy.

Hyperglycemic and small for gestational age. This is incorrect as newborns of diabetic mothers are more likely to be LGA rather than SGA, and they are typically hypoglycemic, not hyperglycemic, after birth.

EXPLANATION

✔Correct answer:

"No, they are usually small due to intrauterine growth restriction." Infants born to drug-dependent women are more likely to experience intrauterine growth restriction (IUGR), which often results in them being small for gestational age (SGA). Substance abuse during pregnancy can lead to poor placental function, reduced nutrient and oxygen delivery to the fetus, and impaired fetal growth. These infants are often born with a lower birth weight and are at increased risk for complications such as preterm birth, withdrawal symptoms (neonatal abstinence syndrome), and developmental delays.

Drug dependency in pregnant women can affect the fetus by impairing placental function and limiting nutrient and oxygen delivery. This can cause chronic hypoxia and malnutrition in the fetus, leading to restricted growth and development. Consequently, these infants are frequently small for gestational age rather than large.

Imagine the fetus as a plant growing in poor soil (representing a compromised placenta due to substance abuse). The plant doesn't get the nutrients and water it needs to grow properly, so it stays small and struggles to thrive, much like an infant with IUGR.

When caring for infants born to drug-dependent mothers, nurses should be vigilant in monitoring for signs of withdrawal (neonatal abstinence syndrome), ensuring adequate nutrition, and providing a supportive environment to promote growth and development.

• Monitor the infant closely for signs of neonatal abstinence syndrome (NAS), including irritability, tremors, poor feeding, and respiratory distress.
• Ensure that the infant is receiving proper nutrition, which may include supplemental feeding to support growth.
• Provide a calm, low-stimulation environment to help the infant manage withdrawal symptoms.
• Educate the mother on the importance of follow-up care and developmental monitoring for the infant.
• Collaborate with social services to provide support and resources for the mother and family.

✘Incorrect answer options:

"Yes, they are often large due to increased nutritional intake during pregnancy." This is incorrect because drug-dependent women often have poor nutritional status and prenatal care, leading to intrauterine growth restriction, not larger infants.

"Yes, they are typically large because of excess amniotic fluid." Excess amniotic fluid (polyhydramnios) can be associated with various conditions, but it does not typically cause infants to be large for gestational age. Moreover, drug dependence in mothers is more commonly linked to restricted growth rather than excessive growth.

"No, they tend to be average in size with no specific growth issues." This is incorrect because infants born to drug-dependent mothers are often SGA due to intrauterine growth restriction. They do not typically have average size and are at risk for several complications due to their prenatal environment.

EXPLANATION

✔Correct answer:

"It means your baby is above the 90th percentile for weight." Large for gestational age (LGA) is a term used to describe newborns who weigh more than the 90th percentile for their gestational age. This means that compared to other babies of the same gestational age, this baby weighs more than 90% of them. Being classified as LGA typically suggests that the baby has grown larger than average, which can be due to factors such as maternal diabetes or pre-pregnancy obesity.

Think of it like a race where babies' weights are compared. If your baby is LGA, it means your baby finished in the top 10% for weight, ahead of most other babies of the same age.

LGA babies might require additional monitoring for potential complications, such as hypoglycemia, birth injuries, or respiratory issues, especially if the mother had conditions like diabetes.

✘Incorrect answer options:

"It means your baby is in the 5th percentile for weight." This statement is incorrect because the 5th percentile would indicate that the baby is small for gestational age (SGA), not LGA.

"It means your baby can be a bit lazy sometimes." This is incorrect and misleading. LGA is related to the baby’s size, not the baby’s activity levels or behavior.

"It means your baby is average for gestational age." This statement is incorrect because an average baby would fall around the 50th percentile for weight, not above the 90th percentile, which defines LGA.

EXPLANATION

✔Correct answer:

The baby may be small for gestational age (SGA). When a pregnant woman is diagnosed with severe anemia, the fetus is at increased risk of being small for gestational age (SGA). Anemia in the mother can lead to decreased oxygen-carrying capacity of the blood, which means the fetus receives less oxygen and nutrients necessary for proper growth and development. This intrauterine growth restriction (IUGR) can result in the fetus not reaching its full growth potential, leading to a lower birth weight and classification as SGA.

Severe maternal anemia results in reduced hemoglobin levels, leading to decreased oxygen supply to the placenta and, subsequently, to the fetus. This insufficient oxygenation and nutrient delivery can impair fetal growth, causing the fetus to be smaller than expected for its gestational age.

Imagine the fetus as a plant in a garden where water (oxygen and nutrients) is scarce. If the plant doesn't get enough water, it won't grow as big as it should, resulting in a smaller plant. Similarly, the fetus may end up smaller when the mother’s blood lacks sufficient oxygen due to anemia.

In cases of maternal anemia, it’s essential to monitor the fetus for signs of growth restriction and to manage the mother’s anemia to improve fetal outcomes.

• Monitor fetal growth through ultrasound to detect any signs of intrauterine growth restriction (IUGR).
• Encourage the mother to adhere to prescribed iron supplements and a diet rich in iron to improve her hemoglobin levels.
• Provide education on the importance of proper prenatal care and nutritional intake to support both maternal and fetal health.
• Collaborate with healthcare providers to consider potential interventions if the anemia is severe and not responding to treatment, such as blood transfusions.

✘Incorrect answer options:

The fetus may be large for gestational age (LGA). This is incorrect because severe anemia typically leads to restricted fetal growth, not excessive growth. LGA is usually associated with factors like maternal diabetes, not anemia.

Risk of hemorrhage. While anemia can increase the risk of maternal hemorrhage during or after delivery due to decreased blood reserves, it does not directly cause hemorrhage in the fetus.

Development of erythroblastosis fetalis. Erythroblastosis fetalis is a condition associated with Rh incompatibility between the mother and fetus, not maternal anemia. This condition involves the destruction of fetal red blood cells by maternal antibodies, which is unrelated to anemia's effects.

EXPLANATION

✔Correct answer:

Low blood sugar levels. Newborns who are large for gestational age (LGA), particularly those born to mothers with diabetes, are at an increased risk of developing hypoglycemia (low blood sugar levels) shortly after birth. This condition occurs because the fetus has been exposed to high glucose levels in utero due to the mother's diabetes, leading to increased insulin production by the fetus. After birth, the sudden drop in glucose supply (as the umbilical cord is cut) and the continued high insulin levels can cause the newborn's blood sugar to drop.

In utero, the fetus is exposed to elevated glucose levels from the diabetic mother. This causes the fetus’s pancreas to produce more insulin to manage the excess glucose. Once born, the newborn's glucose source (maternal blood) is removed, but the insulin levels remain high, leading to a rapid decrease in blood glucose levels, resulting in hypoglycemia.

Think of the newborn’s body like a car engine that has been running on high fuel (glucose) provided by the mother. The baby’s body (engine) gets used to burning this high fuel with lots of insulin (like the car's fuel injectors). When the fuel supply suddenly stops (after birth), the engine still tries to burn fuel at a high rate (high insulin levels), but there's not enough fuel left, leading to low energy (hypoglycemia).

Nurses should closely monitor blood glucose levels in newborns at risk for hypoglycemia, especially within the first few hours after birth. Early detection and prompt treatment are crucial to prevent complications such as seizures or neurological damage.

• Regular monitoring of blood glucose levels, particularly within the first 4 hours after birth.
• Initiate early feedings to help stabilize blood glucose levels.
• If hypoglycemia is detected, provide glucose gel or intravenous glucose as per the healthcare provider's orders.
• Monitor for signs of hypoglycemia, including jitteriness, lethargy, poor feeding, and seizures.
• Educate the parents about the importance of early and frequent feeding to maintain adequate glucose levels.

✘Incorrect answer options:

Elevated blood pressure. While elevated blood pressure can occur in various conditions, it is not typically a concern in newborns, especially in the context of an LGA infant born to a mother with diabetes. The primary concern is hypoglycemia, not hypertension.

Low blood pressure. Low blood pressure is not a common concern in this scenario. The primary issue for LGA newborns of diabetic mothers is hypoglycemia, not hypotension.

High blood sugar levels. While maternal diabetes can cause high blood sugar levels in the fetus before birth, the concern after delivery is low blood sugar levels, not high. The newborn's insulin levels are elevated due to prenatal exposure to high glucose, which can lead to hypoglycemia post-birth.

EXPLANATION

✔Correct answer:

Pre-pregnancy maternal obesity. Pre-pregnancy maternal obesity is a well-established risk factor for having a large for gestational age (LGA) newborn. Obesity in the mother can lead to various metabolic changes, including increased insulin resistance and higher levels of circulating glucose, which can contribute to excessive fetal growth. As a result, the fetus receives more glucose, leading to increased fetal insulin production, which acts as a growth hormone and promotes the deposition of fat and overall larger fetal size.

Maternal obesity is associated with increased insulin resistance, causing higher blood glucose levels. This elevated glucose crosses the placenta and stimulates the fetal pancreas to produce more insulin, leading to enhanced growth and fat deposition in the fetus. This process increases the likelihood of the baby being classified as LGA.

Consider the fetus like a plant in rich soil (maternal environment). If the soil has an excess of nutrients (glucose due to maternal obesity), the plant (fetus) will grow larger than expected due to the abundance of resources.

Recognizing maternal obesity as a risk factor for LGA infants is crucial for prenatal care. Nurse Thompson should focus on monitoring the newborn for potential complications associated with being LGA, such as hypoglycemia, birth injuries, and respiratory distress.

• Monitor the newborn’s blood glucose levels closely to detect and manage hypoglycemia.
• Assess for birth injuries, such as shoulder dystocia or fractures, which are more common in LGA infants.
• Provide education to the mother on the importance of healthy weight management before and during pregnancy to reduce risks in future pregnancies.
• Ensure appropriate follow-up care to monitor the infant's growth and development.

✘Incorrect answer options:

Fetal exposure to low levels of estrogen. There is no direct association between low levels of estrogen and the fetus being LGA. Estrogen primarily supports pregnancy by maintaining the uterine lining and promoting fetal development, but it is not linked to excessive fetal growth.

Inadequate weight gain by the mother during pregnancy. Inadequate weight gain is more commonly associated with small for gestational age (SGA) infants rather than LGA infants. Poor maternal weight gain typically limits fetal growth, leading to lower birth weights.

The mother having had a low birth weight. A mother’s own birth weight does not directly influence her baby’s classification as LGA. Instead, factors like maternal obesity, diabetes, and gestational weight gain are more significant contributors to LGA status.