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. Hypertension: Hypertension is not typically associated with abruptio placentae. In fact, abruptio placentae is often linked to conditions such as chronic hypertension, but the presentation is more commonly associated with symptoms like uterine tenderness, bleeding, and fetal distress.
B. Uterine tenderness: This is the correct answer. Uterine tenderness is a common clinical finding in abruptio placentae. It results from the separation of the placenta from the uterine wall, leading to blood accumulation in the uterine musculature.
C. Leukorrhea: Leukorrhea, a white or yellowish discharge from the vagina, is not a typical finding in abruptio placentae. The condition is characterized by vaginal bleeding and uterine tenderness.
D. Fetal tachycardia: Fetal distress, including fetal tachycardia, is a potential complication of abruptio placentae. However, uterine tenderness is a more immediate and direct finding associated with the separation of the placenta.
Correct Answer is A
Explanation
A. Previous cervical cerclage
Cervical cerclage is a surgical procedure in which a stitch is placed in the cervix to reinforce it and reduce the risk of preterm birth. The fact that the client has had a previous cervical cerclage suggests a history of cervical insufficiency or a shortened cervix, which increases the risk of preterm delivery in subsequent pregnancies.
B. Previous delivery at 37 weeks gestation: A delivery at 37 weeks gestation is considered term. While it is on the earlier side of term, it does not inherently indicate an increased risk for preterm delivery.
C. Previous delivery of a newborn weighing 2.5 kg (5.5 lb): While low birth weight can be associated with preterm birth, the weight alone does not necessarily indicate a history of preterm delivery. Birth weight can be influenced by various factors.
D. Previous reactive non-stress test: A reactive non-stress test is a reassuring result, indicating that the fetus is responsive and generally doing well. It does not suggest a history or risk of preterm delivery.
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