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 .
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale
Amniotic fluid embolism is a life-threatening emergency that can lead to cardiac and respiratory failure. Immediate initiation of cardiopulmonary resuscitation (CPR) is crucial to maintain circulation and oxygenation.
Choice B rationale
Ephedrine is not typically used in the management of amniotic fluid embolism. It is a vasopressor used to treat hypotension, but it is not the primary intervention in this situation.
Choice C rationale
Assessing for the presence of clonus is not relevant in this situation. Clonus is a neurological sign and is not directly related to amniotic fluid embolism.
Choice D rationale
Assisting the client to empty their bladder is not a priority action in this situation. The immediate concern is maintaining the client’s airway, breathing, and circulation.
Correct Answer is D
Explanation
Choice A rationale
Administering a 500 mL lactated Ringer’s IV bolus is not the first action to take when a nurse notes a steady trickle of vaginal bleeding that does not stop with fundal massage.
Choice B rationale
Documenting urinary output is important, but it is not the first action to take when a nurse notes a steady trickle of vaginal bleeding that does not stop with fundal massage.
Choice C rationale
Replacing the surgical dressing is not the first action to take when a nurse notes a steady trickle of vaginal bleeding that does not stop with fundal massage.
Choice D rationale
Notifying the healthcare provider is the correct action. Persistent vaginal bleeding after a cesarean birth could indicate a postpartum hemorrhage, which is a medical emergency
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