A nurse is caring for a newborn who is 4 hours old.

The newborn is lying in a bassinet, lightly swaddled.

The newborn is noted to be jittery with a weak cry when disturbed. Extremities are mottled with acrocyanosis.
Respirations are rapid and unlabored.

What condition is the newborn most likely experiencing? What are two actions the nurse should take to address that condition, and what are two parameters the nurse should monitor to assess the newborn’s progress?

Hypoglycemia

Neonatal Abstinence Syndrome

Cold Stress

Respiratory Distress Syndrome

Answer and Explanation

The Correct Answer is A

Choice A rationale
The newborn’s symptoms of jitteriness, weak cry, mottled extremities with acrocyanosis, and rapid, unlabored respirations are indicative of hypoglycemia. Hypoglycemia in the newborn period can be caused by several factors, including maternal diabetes (gestational or pre- existing), preterm birth, and sepsis. The nurse should take actions to address this condition, such as ensuring the newborn is warm, initiating early feeding to provide the newborn with glucose, and monitoring blood glucose levels.
Choice B rationale
Neonatal Abstinence Syndrome (NAS) is a group of problems that occur in a newborn who was exposed to addictive opiate drugs while in the mother’s womb. NAS can cause a wide range of symptoms such as excessive crying, poor feeding, and seizures. However, the symptoms described in the question are more indicative of hypoglycemia.
Choice C rationale
Cold stress can occur in newborns who are unable to maintain their body temperature within a normal range. While some of the symptoms described, such as mottled skin and acrocyanosis, can occur with cold stress, the presence of jitteriness and a weak cry are more indicative of hypoglycemia.
Choice D rationale
Respiratory Distress Syndrome (RDS) is a common problem in premature babies and is caused by a lack of surfactant in the lungs. While rapid, unlabored respirations can be a sign of RDS, the other symptoms described in the question, such as jitteriness and a weak cry, are not typically associated with RDS2.

Nursing Test Bank

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

Correct Answer is C

Explanation

Choice A rationale
Pale, translucent skin is not typically a characteristic of a postterm newborn. Postterm newborns often have dry, peeling, loose skin.
Choice B rationale
Large deposits of subcutaneous fat are not usually seen in postterm newborns. In fact, these babies may appear abnormally thin, especially if the function of the placenta was severely reduced near the end of the pregnancy.
Choice C rationale
Nails extending over the tips of the fingers is indeed a common characteristic of postterm newborns. This is because the baby has had more time to grow in the womb.
Choice D rationale
A thin covering of fine hair on the shoulders and back is not typically seen in postterm newborns. This characteristic is more commonly associated with preterm babies.

A. Preterm newborns might have a thick layer of brown fat that can cause them to quickly become overheated. B. Preterm newborns might shiver to warm up when they get too cool. C. Preterm newborns might sweat to cool off when they get too warm. D. Preterm newborns might have less muscle tone which exposes more body surfaces to heat loss.

Correct Answer is D

Explanation

Choice A rationale
Preterm newborns do not have a thick layer of brown fat. Brown fat is a type of fat that generates heat and is typically found in full-term newborns. It helps them maintain their body temperature. Preterm newborns have less brown fat, which makes them more susceptible to hypothermia.
Choice B rationale
Shivering is a mechanism used by the body to generate heat when it’s cold. However, preterm newborns cannot shiver. Their nervous systems are not fully developed, and they lack the muscle coordination necessary to shiver.
Choice C rationale
Sweating is another mechanism the body uses to regulate temperature. When the body is too warm, it produces sweat to cool down. However, preterm newborns do not sweat to cool off when they get too warm. Their sweat glands are not fully developed, and they may not be able to sweat effectively.
Choice D rationale
Preterm newborns have less muscle tone, which exposes more body surfaces to heat loss. Muscle tone provides insulation and generates heat. Because preterm newborns have less muscle mass, they have less insulation and generate less heat, making them more susceptible to hypothermia.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is assessing a newborn who was born postterm. Which of the following findings should the nurse expect?

Correct Answer is C

Explanation

A nurse is providing teaching to the guardians of a preterm newborn about temperature instability. Which of the following statements should the nurse make?

Correct Answer is D

Explanation

A nurse is assessing a client for pain following a cesarean birth 24 hours ago. Which should the nurse ask to determine if a PRN pain medication is needed?

A nurse is performing a nutritional assessment for a client during their first prenatal visit at 12 weeks of gestation. Which of the following findings indicates that the client should be referred to a registered dietician?

A nurse has been monitoring a client who gave birth vaginally 8 hours ago. Based on the nurse’s notes at 0700 and 1100, select the three findings that necessitate immediate follow-up.

A nurse is discussing fertility treatment options with a client and their partner. Which of the following non-pharmacological treatments should the nurse suggest?

A nurse is reviewing the medical record of a client who had a vaginal delivery 3 hours ago.Which of the following findings place the client at risk for postpartum hemorrhage? (Select all that apply)

A nurse is assessing a client who is at 6 weeks of gestation and adheres to a vegan diet. Which of the following Questions should the nurse ask to assess the client’s dietary intake?

A nurse is assessing a client who is 1 hour postpartum following a vaginal birth. The nurse notes that the client has excessive vaginal bleeding. What should the nurse do first?

A nurse is providing care to a client who is receiving an epidural block with an opioid analgesic. Which of the following findings should the nurse monitor as a potential adverse effect of the medication?