A nurse is assessing a newborn who is 2 hours old.
Which of the following findings is an indication of hypoglycemia? (Select all that apply)

Abdominal distention

Temperature instability

Acrocyanosis

Hypotonia .

Answer and Explanation

Correct Answer : B,D

Choice A rationale
Abdominal distention is not typically associated with hypoglycemia. It can be a sign of other conditions such as gastrointestinal issues.
Choice B rationale
Temperature instability can be a sign of hypoglycemia. Hypoglycemia can interfere with the body’s ability to regulate temperature.

Choice C rationale
Acrocyanosis, or blueness of the skin, is a common finding in newborns and is not typically associated with hypoglycemia.
Choice D rationale
Hypotonia, or decreased muscle tone, can be a sign of hypoglycemia. When blood sugar levels are low, it can affect muscle function.

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Correct Answer is A

Explanation

Choice A rationale
Facial asymmetry can occur as a result of a forceps-assisted birth. The pressure from the forceps can cause temporary changes in the shape of the baby’s face.
Choice B rationale
Caput succedaneum, a swelling of the scalp in a newborn, is not typically caused by forceps. It is more commonly associated with vacuum extraction.
Choice C rationale
Cephalohematoma, a bleeding underneath one of the cranial bones, is not typically caused by forceps. It is more commonly associated with vacuum extraction.
Choice D rationale

Subgaleal hemorrhage, bleeding into the space between the skull periosteum and the scalp galea aponeurosis, is not typically caused by forceps. It is more commonly associated with vacuum extraction.

A. Move the client onto their hands and knees B. Apply pressure to the client’s fundus C. Assist the client in pulling their knees toward their abdomen D. Press firmly on the client’s suprapubic area

Correct Answer is C

Explanation

Choice A rationale
Moving the client onto their hands and knees is not the primary action taken during the McRoberts maneuver. The McRoberts maneuver involves an obstetrician or other healthcare provider flexing the patient’s thighs toward their abdomen.
Choice B rationale

Applying pressure to the client’s fundus is not the primary action taken during the McRoberts maneuver. The McRoberts maneuver involves an obstetrician or other healthcare provider flexing the patient’s thighs toward their abdomen.
Choice C rationale
This is the correct answer. The McRoberts maneuver involves an obstetrician or other healthcare provider flexing the patient’s thighs toward their abdomen. This maneuver helps to rotate the pelvis and open the sacrum to release the baby’s shoulder.
Choice D rationale
Pressing firmly on the client’s suprapubic area is not the primary action taken during the McRoberts maneuver. The McRoberts maneuver involves an obstetrician or other healthcare provider flexing the patient’s thighs toward their abdomen.

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A nurse is assessing a newborn who is 2 hours old. Which of the following findings is an indication of hypoglycemia? (Select all that apply)

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A nurse is assessing a newborn who is 2 hours old.
Which of the following findings is an indication of hypoglycemia? (Select all that apply)