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
Temperature instability
Hypotonia
Jitteriness
Correct Answer : D,E
A. Abdominal distention:
Abdominal distention is not typically associated with hypoglycemia in newborns. It may be caused by other factors such as swallowed air during feeding or gastrointestinal issues.
B. Acrocyanosis:
Acrocyanosis, which is the blueness of the hands and feet, is a common finding in newborns and is not specific to hypoglycemia. It is often a result of the newborn's immature circulatory system.
C. Temperature instability:
Temperature instability, including hypothermia or hyperthermia, can occur in newborns for various reasons, but it is not specific to hypoglycemia.
D. Hypotonia:
Hypotonia, or decreased muscle tone, can be a sign of hypoglycemia in newborns. It may present as decreased activity, floppy movements, or poor feeding.
E. Jitteriness
Jitteriness, which is characterized by tremors or shaky movements, is a common manifestation of hypoglycemia in newborns. It is often observed when the newborn's blood glucose levels are low and can be a significant sign of hypoglycemia.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A.Dry mucous membranes may indicate dehydration. The newborn is breastfeeding only 3–4 times per day, which is lower than the recommended 8–12 feedings per day for adequate hydration and nutrition.
B.Yellow sclera suggests jaundice, which could indicate neonatal hyperbilirubinemia. Since the newborn is Coombs-positive, there is an increased risk of hemolytic disease of the newborn (HDN) due to blood incompatibility, making bilirubin monitoring essential.
D.The newborn has voided only once in 36 hours, which may indicate dehydration or inadequate fluid intake. Additionally, the absence of a meconium stool may suggest intestinal obstruction, delayed passage, or meconium plug syndrome, requiring further evaluation.
E.A positive Coombs test means that maternal antibodies have attacked the newborn’s red blood cells, increasing the risk of hemolytic anemia and jaundice. This finding correlates with the yellow sclera, necessitating further bilirubin monitoring.
Incorrect answers:
C.Caput succedaneum is benign and self-resolving. It is a soft tissue swelling from birth trauma and does not require intervention.
F.A respiratory rate of 44 breaths/min is within the normal range (30–60 breaths/min) for a newborn and does not indicate distress.
Correct Answer is D
Explanation
A. Encourage the client to apply a warm pack to the perineum for discomfort.
While warm packs can provide comfort and promote relaxation for some types of perineal discomfort, they may not be suitable for a third-degree perineal laceration. In fact, applying heat directly to the perineum may exacerbate swelling and increase discomfort in this particular case. Therefore, it is not the most appropriate intervention for this client.
B. Prepare the client for a pudendal nerve block.
A pudendal nerve block is typically used during labor or for specific procedures (such as episiotomy repair) to provide pain relief. It is not a routine intervention for postpartum perineal lacerations.
C. Apply hydrogel pads to the perineum every 4 hr.
While hydrogel pads can provide some relief for perineal discomfort, they are not typically used specifically for third-degree perineal lacerations. These types of lacerations require medical intervention and repair rather than solely relying on over-the-counter remedies like hydrogel pads. Therefore, this intervention may not address the underlying issue effectively.
D. Place a witch hazel pad on the client's perineal pad after each voiding.
Witch hazel pads can provide soothing relief to the perineum and help reduce swelling and discomfort after childbirth. They have a cooling effect and can also have mild astringent properties, which may aid in promoting healing.Placing a witch hazel pad on the perineal pad after each voiding helps ensure that the perineum remains clean and that the client experiences continuous relief from discomfort
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