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

Answer and Explanation

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.

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Correct Answer is B

Explanation

a.This may help with incision pain or swelling but does not address the ongoing vaginal bleeding.

b.Administering a bolus of lactated Ringer's solution helps to restore fluid volume and maintain blood pressure, which is crucial in managing persistent vaginal bleeding. This action addresses the immediate concern of fluid loss and helps stabilize the patient while further assessments and interventions can be made.

c.While important for monitoring the incision, it does not address the immediate issue of ongoing vaginal bleeding.

d.Important to monitor, but not the first priority in the context of ongoing bleeding. This can be assessed after addressing the bleeding issue.

A. Airborne B. Droplet C. Protective environment D. Contact

Correct Answer is D

Explanation

Explanation:

A. Airborne precautions:

Airborne precautions are used for pathogens that are transmitted through the air over long distances. This includes pathogens such as Mycobacterium tuberculosis (TB) or varicella-zoster virus (chickenpox). However, Clostridium difficile (C. difficile) infection is not transmitted through the airborne route. Therefore, airborne precautions are not appropriate for managing C. difficile infection.

B. Droplet precautions:

Droplet precautions are used for pathogens that are transmitted through respiratory droplets, typically over short distances (usually within about 3 feet). This includes pathogens such as influenza virus or Bordetella pertussis (whooping cough). However, C. difficile infection is primarily transmitted through the fecal-oral route and contact with contaminated surfaces or objects, rather than through respiratory droplets. Therefore, droplet precautions are not appropriate for managing C. difficile infection.

C. Protective environment:

Protective environment, also known as reverse isolation, is used to protect immunocompromised clients from pathogens in the environment. This includes clients who have undergone bone marrow transplantation or chemotherapy. However, protective environment precautions are not appropriate for managing C. difficile infection. C. difficile infection control measures primarily focus on preventing the spread of the infection to others, rather than protecting the client from external pathogens.

D. Contact precautions:

Contact precautions are used for pathogens that are transmitted through direct or indirect contact with the client or their environment. This includes pathogens such as methicillin-resistant Staphylococcus aureus (MRSA) or C. difficile. C. difficile infection is primarily transmitted through contact with contaminated surfaces or objects. Therefore, contact precautions, which involve measures to prevent the transmission of infectious agents via contact, including wearing gloves and a gown, performing hand hygiene, and ensuring environmental cleaning and disinfection, are appropriate for managing C. difficile infection.

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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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