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A nurse is assessing a newborn.
Which of the following findings indicates a need to check the newborn's blood glucose level for hypoglycemia?

Shrill cry.

Weak peripheral pulses.

Yellowish skin.

Hypotonia.

Answer and Explanation

The Correct Answer is D

Choice A rationale

A shrill cry may indicate distress but isn't specifically related to hypoglycemia in newborns.

Choice B rationale

Weak peripheral pulses are more commonly associated with circulatory or cardiac issues rather than hypoglycemia.

Choice C rationale

Yellowish skin suggests jaundice, which is due to elevated bilirubin levels, not hypoglycemia.

Choice D rationale

Hypotonia, or decreased muscle tone, can be a sign of hypoglycemia in newborns, indicating a need to check blood glucose levels.

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Correct Answer is C

Explanation

Choice A rationale

Giving glucose water after feedings is not recommended for newborns undergoing phototherapy. Breastfeeding or formula feeding should be continued to provide adequate nutrition and hydration.

Choice B rationale

Instructing the client to avoid breastfeeding during treatment is not necessary. Breastfeeding should continue to promote bonding, provide nutrition, and help with the infant's hydration and bilirubin excretion.

Choice C rationale

Monitoring intake and output is crucial for a newborn receiving phototherapy to ensure proper hydration and assess the effectiveness of the treatment in lowering bilirubin levels.

Choice D rationale

Applying lotions and ointments throughout the treatment is not recommended, as they can interfere with the effectiveness of phototherapy. The skin should be clean and dry to maximize exposure to the phototherapy light.

A. Elevate the head of the client's bed. B. Administer a dose of terbutaline. C. Initiate oxygen at 2 L/min via nasal cannula. D. Initiate an infusion of oxytocin.

Correct Answer is D

Explanation

Choice A rationale

Elevating the head of the client’s bed is not indicated in this situation and does not address the issue of excessive bleeding postpartum.

Choice B rationale

Administering terbutaline, a medication used to manage preterm labor, is not relevant in the context of postpartum hemorrhage and excessive bleeding.

Choice C rationale

Initiating oxygen at 2 L/min via nasal cannula may help with oxygenation but does not address the primary issue of excessive postpartum bleeding.

Choice D rationale

Initiating an infusion of oxytocin is the correct action as it helps contract the uterus and reduce postpartum bleeding, making it a crucial step in managing this situation.

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A nurse is assessing a newborn.Which of the following findings indicates a need to check the newborn's blood glucose level for hypoglycemia?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a 2-day-old newborn who has a bilirubin level of 14 mg/dL (1 to 12 mg/dL) and is to begin phototherapy.Which of the following actions should the nurse take?

Correct Answer is C

Explanation

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Correct Answer is D

Explanation

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A nurse is assessing a newborn.
Which of the following findings indicates a need to check the newborn's blood glucose level for hypoglycemia?