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 B
Explanation
A. Urinary output 40 mL/hr: Decreased urinary output can be an indicator of inadequate fluid intake or other issues, but it is not a specific sign of hemorrhage.
B. Blood pressure 88/40 mm Hg: This is the correct answer. A low blood pressure, especially with a low diastolic pressure, can be indicative of hypovolemic shock, which may result from postpartum hemorrhage. Hemorrhage leads to a decrease in circulating blood volume, causing a drop in blood pressure.
C. Moderate rubra lochia: Lochia is the normal vaginal discharge experienced after childbirth, and moderate rubra lochia is considered within the expected range for the early postpartum period. It is not a specific sign of hemorrhage.
D. Heart rate 90/min: A heart rate of 90 beats per minute is within the normal range for a postpartum client and may not be a specific sign of hemorrhage. However, an increase in heart rate could be an early indicator of hypovolemia due to hemorrhage.
Correct Answer is B
Explanation
Correct Answer: B
B. Administer broad-spectrum antibiotics
Newborns with a leaking myelomeningocele are at a high risk for infection, especially meningitis, due to the exposure of cerebrospinal fluid (CSF). Administering broad-spectrum antibiotics helps reduce the risk of infection until the defect is surgically closed.
Incorrect answers:
A.Monitor the rectal temperature every 4 hr.Taking rectal temperatures is contraindicated in a newborn with a myelomeningocele due to the risk of trauma to the rectum and potential introduction of bacteria near the exposed spinal cord and CSF. Axillary temperatures should be used instead.
C.Prepare for surgical closure after 72 hr.Surgical repair of a myelomeningocele is typically performed within the first 24–48 hours of life to reduce the risk of infection and prevent further nerve damage.
D.Cleanse the site with povidone-iodine. Povidone-iodine is not appropriate for cleansing the exposed myelomeningocele site because it can be too harsh and toxic to neural tissue.
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