A nurse is assessing a newborn whose mother had gestational diabetes. Which of the following findings should the nurse identify as a manifestation of hypoglycemia?
Hypertonia.
Jitteriness.
Acrocyanosis.
Generalized petechiae.
The Correct Answer is B
Choice A rationale:
Hypertonia (increased muscle tone) is not a manifestation of hypoglycemia in a newborn. Instead, hypotonia (decreased muscle tone) is more characteristic.
Choice B rationale:
This is the correct choice. Jitteriness is a common sign of hypoglycemia in a newborn. It may be accompanied by other symptoms like poor feeding, tremors, and irritability.
Choice C rationale:
Acrocyanosis (bluish discoloration of the hands and feet) is a normal finding in newborns and is not specifically associated with hypoglycemia.
Choice D rationale:
Generalized petechiae (small red or purple spots on the skin caused by bleeding under the skin) are not indicative of hypoglycemia but may be associated with other medical conditions.
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Related Questions
Correct Answer is C
Explanation
Choice A rationale:
While there is a risk of infection with any internal examination, it is not the primary reason for avoiding internal examinations in a client with placenta previa. The main concern is avoiding trauma to the placenta, which could result in significant bleeding.
Choice B rationale:
Although internal examinations may potentially stimulate uterine contractions, leading to preterm labor in some cases, this is not the primary reason for avoiding such examinations in clients with placenta previa. The primary concern remains the risk of bleeding due to placental disruption.
Choice C rationale:
The correct explanation for the nurse to provide is that an internal examination could result in profound bleeding. Placenta previa occurs when the placenta partially or completely covers the cervix, and any manipulation of the cervix or uterus through an internal examination could disrupt the placenta and cause severe bleeding, endangering both the mother and the baby.
Choice D rationale:
While there is a risk of rupturing the membranes during an internal examination, this is not the primary reason for avoiding such examinations in clients with placenta previa. The primary concern remains the risk of bleeding due to placental disruption.
Correct Answer is A
Explanation
Choice A rationale:
The nurse should include in the teaching that a yearly Pap test is recommended until 70 years of age. This recommendation is based on current guidelines, which state that women should start getting Pap tests at age 21 and continue every three years until they reach the age of 65. However, if they undergo HPV testing along with the Pap test and have consistently negative results, they can extend the screening interval to every five years. After the age of 65, if they have had regular screenings with normal results, they may discontinue Pap testing.
Therefore, it is important to clarify the appropriate age range for the Pap test to ensure the client's understanding and compliance with screening guidelines.
Choice B rationale:
The nurse should not include choice B, "Pap tests are discontinued following removal of the ovaries,” in the teaching. The presence or absence of ovaries does not affect the need for Pap testing. The Pap test is primarily used to screen for cervical cancer, and its necessity is determined based on age and previous screening results, not on ovarian status.
Choice C rationale:
The nurse should not include choice C, "Avoid having sexual intercourse for 24 hours prior to the Pap test,” in the teaching. While it is generally recommended to avoid vaginal intercourse and douching for at least 24 hours before a Pap test, it is not the most crucial information to include in this context. The primary teaching point should focus on the recommended age range and frequency of Pap tests.
Choice D rationale:
The nurse should not include choice D, "Viral infections can be detected by a Pap test,” in the teaching. The Pap test is not designed to detect viral infections. Instead, it is used to detect abnormal cervical cells, which may indicate pre-cancerous or cancerous changes.
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