A nurse is assessing a newborn whose mother had gestational diabetes mellitus. The nurse should monitor for which of the following findings as a manifestation of hypoglycemia?
Abdominal distention.
Petechiae.
Increased muscle tone.
Jitteriness.
The Correct Answer is D
Choice A rationale:
Abdominal distention is not a typical manifestation of hypoglycemia in a newborn. Instead, it can be associated with gastrointestinal issues or other conditions affecting the abdominal organs.
Choice B rationale:
Petechiae are small, pinpoint purple or red spots that appear on the skin due to broken capillaries. They are not related to hypoglycemia and can be caused by various factors such as blood clotting disorders or infections.
Choice C rationale:
Increased muscle tone is not typically associated with hypoglycemia in a newborn. Instead, hypoglycemic babies may exhibit decreased muscle tone, lethargy, and poor feeding.
Choice D rationale:
Jitteriness is a common manifestation of hypoglycemia in newborns. It is characterized by rhythmic tremors, often involving the face and extremities. This occurs because the brain relies heavily on glucose for energy, and low blood sugar levels can affect neurological function, leading to jitteriness. Prompt intervention is necessary to prevent further complications.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale:
The nurse should assess this client first as they are at 34 weeks of gestation and experiencing epigastric pain and headache. These symptoms could be indicative of preeclampsia, a serious pregnancy complication characterized by high blood pressure and organ damage. Preeclampsia requires immediate assessment and intervention to prevent further complications.
Choice B rationale:
Nausea and vomiting are common symptoms during the first trimester of pregnancy, and at 12 weeks of gestation, it is less likely to be a critical issue compared to potential preeclampsia.
Choice C rationale:
Painful urination may indicate a urinary tract infection, which can be important to assess and treat, but it is not as urgent as potential signs of preeclampsia in a client at 34 weeks of gestation.
Choice D rationale:
Cramping and spotting can be normal signs of impending labor, especially at 39 weeks of gestation. While it's important to assess this client, it is not the priority over potential preeclampsia in a client at 34 weeks of gestation with symptoms of epigastric pain and headache.
Correct Answer is B
Explanation
Choice A rationale:
Swaddling the baby tightly with his legs extended before laying him down to sleep is not a recommended practice, as it can increase the risk of hip dysplasia. Instead, the baby should be placed on their back in a safe sleep environment.
Choice B rationale:
This statement is correct because monitoring the baby's urinary output is essential in ensuring adequate hydration and proper kidney function. Less than six wet diapers a day could be a sign of dehydration and should be promptly reported to the pediatrician.
Choice C rationale:
It is not necessary to retract the foreskin to clean the baby's penis during each bath. The foreskin should be left alone and not forcibly retracted until it naturally loosens, usually around the age of 3 to 5 years.
Choice D rationale:
Applying triple antibiotic ointment on the baby's umbilical cord is not recommended, as the standard practice is to keep the umbilical cord clean and dry. This helps it to fall off naturally within a week or two after birth, reducing the risk of infection.
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