A nurse is assessing a newborn who has hypoglycemia due to perinatal asphyxia.
Which of the following findings should the nurse expect? (Select all that apply.)
Irregular respirations
Cyanosis
Apnea
Eye-rolling
Lethargy
Correct Answer : A,C,D,E
The correct answer is choice A, C, D, and E. Hypoglycemia due to perinatal asphyxia can cause various neurological signs in the newborn, such as irregular respirations, apnea, eye-rolling, and lethargy.
These signs indicate inadequate oxygenation and glucose delivery to the brain. Cyanosis is not a specific sign of hypoglycemia, but rather a sign of poor oxygenation that can occur due to other causes.
Therefore, choice B is wrong.
Choice A is correct because irregular respirations can result from hypoglycemia due to perinatal asphyxia. Hypoglycemia can impair the respiratory center in the brainstem and cause irregular breathing patterns.
Choice C is correct because apnea can result from hypoglycemia due to perinatal asphyxia.
Apnea is defined as a pause in breathing
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
The correct answer is choice A.Washing hands before and after handling the cord stump can prevent the transmission of bacteria that can cause omphalitis, sepsis, and tetanus.
Choice B is wrong because applying petroleum jelly or ointment to the cord stump can delay its drying and increase the risk of infection.
Choice C is wrong because using hydrogen peroxide to clean the cord stump can damage the healthy tissue and delay healing.
Choice D is wrong because folding down the diaper below the cord stump can expose it to urine and feces, which can contaminate it and cause infection.
The normal range for umbilical cord separation is 5 to 15 days after birth.
Correct Answer is B
Explanation
The correct answer is choice B. Give the vaccine intramuscularly in the anterolateral thigh.
This is because the anterolateral thigh is the recommended site for intramuscular injections in infants less than 12 months of age.
It has a large muscle mass and minimal risk of injury to nerves or blood vessels.
Choice A is wrong because informed consent is not required for routine immunizations, unless the parent or guardian requests more information or declines the vaccine.
Choice C is wrong because hepatitis B immune globulin (HBIG) is only indicated for newborns whose mothers are hepatitis B surface antigen positive (HBsAg+), as they have a high risk of acquiring the infection from their mothers.
Choice D is wrong because there is no need to delay giving the vaccine until after breastfeeding is established.
Breastfeeding does not interfere with the vaccine’s effectiveness or safety, and it does not increase the risk of adverse reactions.
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