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.

Jitteriness.

Acrocyanosis.

Hypotonia.

Temperature instability.

Answer and Explanation

Correct Answer : B,D,E

Choice A rationale:
Abdominal distention is not typically a sign of hypoglycemia in a newborn. It could be related to other factors such as feeding issues or gastrointestinal problems.
Choice B rationale:
Jitteriness can be a sign of hypoglycemia in a newborn as low blood sugar can cause nervous system hyperactivity.
Choice C rationale:
Acrocyanosis, or bluish discoloration of the hands and feet, is common in newborns and is not typically a sign of hypoglycemia.
Choice D rationale:
Hypotonia, or decreased muscle tone, can be a sign of hypoglycemia in a newborn as low blood sugar can affect muscle function.
Choice E rationale:
Temperature instability can be a sign of hypoglycemia in a newborn as low blood sugar can affect the body’s ability to regulate temperature.

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Correct Answer is D

Explanation

Choice A rationale:
Demonstrating proper bathing of the infant is incorrect. This is a goal for the taking-hold phase, not the taking-in phase.
Choice B rationale:
Verbalizing appropriate car seat safety is incorrect. This is a goal for the taking-hold phase, not the taking-in phase.
Choice C rationale:
Identifying individual family member roles is incorrect. This is a goal for the taking-hold phase, not the taking-in phase.
Choice D rationale:
Having adequate nutritional intake is correct. During the taking-in phase, the mother is focused on her own needs, including nutrition.

A. The client reports a feeling of vaginal fullness. B. The client's fundus is firm and midline. C. The client saturates a perineal pad in 1 hr. D. The client's umbilical cord lengthens.

Correct Answer is B

Explanation

Choice A rationale:
A feeling of vaginal fullness is not a therapeutic effect of oxytocin. It could indicate a vaginal hematoma or retained placental fragments.
Choice B rationale:
The client’s fundus is firm and midline. This is the expected therapeutic effect of oxytocin. It stimulates uterine contractions to prevent postpartum hemorrhage.
Choice C rationale:
Saturating a perineal pad in 1 hr could indicate postpartum hemorrhage, which is not a therapeutic effect of oxytocin.
Choice D rationale:
The client’s umbilical cord lengthening is not related to oxytocin administration. It could indicate placental separation.

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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.).

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is planning care for a client in the postpartum unit. Which of the following goals should the nurse identify for the client to accomplish during the taking-in phase of postpartum adjustment?.

Correct Answer is D

Explanation

A nurse is caring for a client who is in the third stage of labor and has a prescription for IV oxytocin administration following expulsion of the placenta. Which of the following clinical manifestations should the nurse expect as a therapeutic effect of the medication?

Correct Answer is B

Explanation

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