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 D

Explanation

Choice A rationale
Decreasing the rate of IV fluids would not address the issue of late decelerations, which are a sign of fetal hypoxia.
Choice B rationale
Elevating the client’s head would not address the issue of late decelerations.
Choice C rationale
Performing fetal scalp stimulation is used to assess fetal well-being when the tracing is nonreactive, not when late decelerations are present.

Choice D rationale
Administering oxygen via a face mask is the correct answer. This increases maternal oxygen saturation, which can help increase oxygen delivery to the fetus.

A. Prepare the client to receive a plasma expander. B. Administer oxygen via face mask at 10 L/min. C. Insert an indwelling urinary catheter. D. Collect hemoglobin and hematocrit levels.

Correct Answer is B

Explanation

Choice A rationale
Preparing the client to receive a plasma expander is not the first action the nurse should take. While it may be necessary in severe cases of hemorrhage, the first action should be to ensure the client’s oxygenation.
Choice B rationale
Administering oxygen via face mask at 10 L/min is the first action the nurse should take. This is because a client who is saturating perineal pads every 10 to 15 minutes is likely experiencing a significant blood loss, which can lead to hypoxia.
Choice C rationale
Inserting an indwelling urinary catheter may be necessary in some cases, but it is not the first action the nurse should take.
Choice D rationale
Collecting hemoglobin and hematocrit levels is important to assess the extent of blood loss, but it is not the first action the nurse should take.

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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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Naxlex Comprehensive Predictor Exams

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Explanation

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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)