A nurse is assessing a newborn for manifestations of hypoglycemia. Which of the following findings should the nurse expect?
jitteriness
Hypertonia
Abdominal distention
Mottling
The Correct Answer is A
The correct answer is A. Jitteriness.
A. Jitteriness: Jitteriness is a common manifestation of hypoglycemia in newborns. It is a tremulous movement that can be observed in response to low blood glucose levels.
B. Hypertonia: Hypertonia, or increased muscle tone, is not a typical manifestation of hypoglycemia in newborns. Instead, hypoglycemia is more likely to be associated with hypotonia or limpness.
C. Abdominal distention: Abdominal distention is not a typical sign of hypoglycemia in newborns. It may be associated with other conditions, such as gastrointestinal issues, but it is not directly related to low blood glucose levels.
D. Mottling: Mottling refers to a blotchy or uneven skin color and is not a specific sign of hypoglycemia. It can be associated with various conditions, including poor circulation, but it is not a primary indicator of low blood glucose.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A Reason:
Reassess the client in 2 hours is inappropriate. While reassessment is important, addressing the cause of uterine displacement, in this case, a full bladder, should be the initial priority.
Choice B Reason:
Administering simethicone is inappropriate. Simethicone is typically used to relieve gas and bloating. It is not the primary intervention for uterine displacement related to bladder fullness.
Choice C Reason:
Assisting the client to empty her bladder is appropriate. A full bladder can displace the uterus and hinder its contraction, leading to potential issues such as uterine atony or increased postpartum bleeding. Emptying the bladder helps the uterus contract more effectively.
Choice D Reason:
Instructing the client to lie on her right side is inappropriate. Lying on the right side is often recommended to improve blood flow and oxygenation to the fetus during pregnancy but may not directly address uterine displacement caused by a full bladder. The priority is to assist the client in emptying her bladder.
Correct Answer is B
Explanation
The correct answer is B. Position the client with one hip elevated.
A. Having the client void is a good practice, but it is not the priority action in this situation. The client's vital signs suggest a potential issue with uteroplacental perfusion, and repositioning the client should be the priority.
B. Positioning the client with one hip elevated is the priority action.
The vital signs, specifically the low blood pressure, may be indicative of aortocaval compression (supine hypotension). Elevating one hip helps alleviate this compression, improving blood flow and potentially addressing the decreased blood pressure.
C. Asking the client if she needs pain medication is important, but repositioning the client takes precedence due to the potential issue with blood pressure and uteroplacental perfusion.
D. Notifying the provider is important, but repositioning the client to improve blood flow should be done first. The provider may be notified afterward based on the client's response and ongoing assessment.
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