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

Answer and Explanation

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.

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Correct Answer is B

Explanation

A. The client cleans the perineum with a squeeze bottle after urinating: This action is appropriate for postpartum perineal care. Using a squeeze bottle to cleanse the perineum with warm water after urination helps maintain cleanliness without causing trauma to the area.

B. The client is changing the perineal pad once daily: Changing the perineal pad once daily is not optimal for wound healing. Postpartum perineal wounds require frequent changing of pads to maintain cleanliness, prevent infection, and promote healing.

C. The client is using witch hazel pads on the perineum: Using witch hazel pads is a common practice for postpartum perineal care. Witch hazel has a soothing effect and can help reduce inflammation and discomfort without negatively affecting wound healing.

D. The client's perineal suture line is well-approximated: A well-approximated perineal suture line is a positive finding, indicating that the edges of the wound are properly aligned and closed, which supports the healing process.

A. Report of perineal pain as 0 on a scale of 0 to 10 B. Report of relief of pruritus C. Increased urinary output D. Blood pressure 110/70 mm Hg

Correct Answer is D

Explanation

A. Report of perineal pain as 0 on a scale of 0 to 10: Perineal pain is more directly related to the effects of spinal anesthesia rather than fluid status. A decrease in perineal pain would be expected after the administration of spinal anesthesia, but it may not specifically indicate the effectiveness of the IV bolus.

B. Report of relief of pruritus: Pruritus (itching) is a common side effect of spinal anesthesia. Relief of pruritus can be expected after the administration of spinal anesthesia, but it is not a direct indicator of the effectiveness of the IV bolus.

C. Increased urinary output: Increased urinary output may indicate improved renal perfusion or fluid balance but is not a specific indicator of the effectiveness of the IV bolus in the context of spinal anesthesia for labor.

D. Blood pressure 110/70 mm Hg: This is the correct answer. Blood pressure is an important parameter to monitor, especially after administering an IV bolus of fluids. A blood pressure within the normal range (110/70 mm Hg) suggests that the bolus has been effective in addressing any hypovolemia or dehydration.

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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.)

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