A nurse is assessing a newborn who is 2 hr old. Which of the following findings is an indication of hypoglycemia? (Select all that apply.)
Abdominal distention
Acrocyanosis
Hypotonia
Jitteriness
Temperature instability
Correct Answer : C,D,E
A. Abdominal distention:
Explanation: Abdominal distention is more commonly associated with issues such as gas or gastrointestinal discomfort. It is not a typical sign of hypoglycemia.
B. Acrocyanosis:
Explanation: Acrocyanosis, a bluish discoloration of the extremities, is a common finding in newborns and is often unrelated to hypoglycemia. It is generally considered a normal response in the early hours or days of life.
C. Hypotonia:
Explanation: Hypotonia, or decreased muscle tone, can be associated with hypoglycemia. It may present as limpness or weakness in the newborn.
D. Jitteriness:
Explanation: Jitteriness, which is tremors or shakiness, can be a sign of hypoglycemia in a newborn. It is a result of the central nervous system responding to low blood glucose levels.
E. Temperature instability:
Explanation: Temperature instability, such as difficulty maintaining a stable body temperature, can be indicative of hypoglycemia. The newborn's ability to regulate temperature may be affected.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. Applying hydrating lotion to the newborn's skin prior to treatment is not recommended as lotions or creams can interfere with the effectiveness of phototherapy and may increase the risk of skin irritation or burns.
B. Turning the newborn every 4 hours is insufficient; the newborn should be turned more frequently, typically every 2 hours, to ensure even exposure to the phototherapy light and to prevent pressure sores.
C. Provide the newborn with 15 ml glucose water after each feeding: This is not a standard practice related to phototherapy. Feeding frequency and amounts are determined by the infant's age, weight, and feeding readiness, but providing glucose water after each feeding is not a routine recommendation.
D. Close the newborn's eyes before applying eyepatches: This is the correct answer. Eyepatches are used during phototherapy to protect the newborn's eyes from exposure to the bright lights. Closing the newborn's eyes before applying eyepatches helps shield the eyes from the light source and prevents potential damage to the eyes.
Correct Answer is B
Explanation
A. Plan to administer ephedrine IV: Ephedrine is a medication commonly used to treat hypotension. While addressing hypotension may be necessary in the management of AFE, the priority is to initiate immediate life-saving measures, such as CPR.
B. Prepare to initiate cardiopulmonary resuscitation: This is the correct answer. In the event of AFE, the client may experience sudden cardiovascular collapse and respiratory distress. Prompt initiation of CPR is crucial to support vital functions and improve the chances of survival.
C. Assist the client to empty their bladder: While assisting the client to empty the bladder is a routine measure, it is not the priority in the management of AFE. Immediate attention to the life-threatening complications is necessary.
D. Assess the presence of clonus: Clonus refers to a series of involuntary, rhythmic, muscular contractions and relaxations. While neurological signs may be assessed in the overall evaluation of a client, it is not the priority in the acute management of AFE.
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