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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
The correct answer is C. Assess the fetal heart rate.
A. Providing clean, dry underpads is important for maintaining cleanliness and comfort, but it is not the priority immediately following an amniotomy.
B. Monitoring the client's temperature is a consideration but is not the priority immediately following an amniotomy. Assessing the fetal well-being takes precedence.
C. Assessing the fetal heart rate is the priority action.
Following an amniotomy, there is a risk of cord prolapse or compression, and assessing the fetal heart rate helps detect any signs of fetal distress or compromise.
D. Assessing the odor of the amniotic fluid may be relevant, but it is not the immediate priority after an amniotomy. Focusing on fetal well-being is crucial.
Correct Answer is A
Explanation
Choice A Reason:
"You can miss your period for several other reasons. Describe your typical menstrual cycle." This response acknowledges that a missed period can result from various factors other than pregnancy, such as stress, changes in weight, hormonal fluctuations, or certain medical conditions. Understanding the client's typical menstrual cycle can help the nurse gather more information about potential reasons for the late period.
Choice B Reason:
"If you have been sexually active and haven't used protection, it is likely that you are pregnant. “This response assumes pregnancy without exploring other possibilities or the client's individual situation.
Choice C Reason:
"Let's check to see if you have any other signs of pregnancy. Have you noticed any abdominal enlargement yet?" While considering other signs of pregnancy is reasonable, focusing on abdominal enlargement may not be the most accurate early indicator, and it's essential to explore a broader range of symptoms.
Choice D Reason:
"Because you have missed your period, you should try taking a home pregnancy test before you start worrying. "While suggesting a home pregnancy test is reasonable, it may be more beneficial to gather additional information about the client's menstrual cycle and potential symptoms before jumping directly to a test.
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