A neonate is admitted, and the nurse notes the blood glucose level is 35 milligrams per deciliter.
The nurse should monitor the neonate for.
Jaundice.
Erythema toxicum.
Jitters, tremors.
Subconjunctival hemorrhage.
The Correct Answer is C
Choice A rationale
Jaundice, or hyperbilirubinemia, is a common neonatal condition resulting from the breakdown of red blood cells, which causes yellowing of the skin. While common in neonates, it is not an immediate clinical sign of acute hypoglycemia (blood glucose less than 40 to 45 milligrams per deciliter), which primarily affects neurological function.
Choice B rationale
Erythema toxicum is a benign, transient rash common in neonates, characterized by erythematous macules and pustules of unknown etiology. This skin finding is unrelated to acute metabolic states such as hypoglycemia, which manifests predominantly with signs of central nervous system dysfunction due to lack of glucose.
Choice C rationale
Jitters and tremors are classic and early neurological signs of neonatal hypoglycemia, as the brain relies almost exclusively on glucose for energy. When blood glucose is low (35 mg/dL), the central nervous system becomes irritable, leading to increased sympathetic output and neuromuscular excitability, manifesting as tremulousness.
Choice D rationale
Subconjunctival hemorrhage is a minor, typically benign finding caused by rupture of small blood vessels in the eye during the pressure changes of labor and delivery. It is a localized, traumatic injury and has no association with systemic metabolic disturbances like hypoglycemia.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A rationale
While a shunt insertion for hydrocephalus aims to drain excess cerebrospinal fluid and reduce intracranial pressure, thereby minimizing brain damage, it does not completely eliminate the risk of developmental problems. The extent of pre-existing neurological damage influences long-term outcomes, and some children may still experience learning disabilities or motor deficits requiring ongoing therapy and support.
Choice B rationale
The risk of shunt infection is present throughout the device's life, although the greatest risk does occur in the early post-operative period, typically within the first few months. Infections can be caused by skin flora introduced during surgery and can lead to serious complications like ventriculitis or septicemia, often requiring shunt removal and IV antibiotics.
Choice C rationale
Shunts have a fixed length; as the child grows, the distal catheter (the end draining the fluid) may no longer reach the peritoneal cavity or atrium, leading to shunt malfunction. Furthermore, components can fail over time due to wear or blockage, necessitating surgical revisions or replacement throughout the individual's lifetime to maintain proper cerebrospinal fluid drainage.
Choice D rationale
A ventriculoperitoneal or ventriculoatrial shunt is a palliative measure that manages the primary complication of hydrocephalus, which is increased intracranial pressure. However, shunts are prone to complications such as malfunction due to blockage, disconnection, or infection, and they do not cure the underlying cause, meaning that further complications remain a possibility.
Correct Answer is D
Explanation
Choice A rationale
Increased intracranial pressure (ICP) typically presents with an irregular respiratory pattern, such as Cheyne-Stokes or central neurogenic hyperventilation, not rapid, shallow breathing, which is more characteristic of metabolic acidosis or shock. A change in the rate and rhythm of breathing is a late and ominous sign, often indicating brainstem compression and severe deterioration.
Choice B rationale
Late-stage, severe ICP elevation that progresses to Cushing's triad typically causes a bradycardia, which is an irregular, slow heart rate, rather than a rapid one. A rapid heart rate (tachycardia) is more commonly associated with hypovolemic shock or fever. Bradycardia is a parasympathetic response to the body's attempt to maintain cerebral perfusion pressure.
Choice C rationale
Increased ICP is characterized by Cushing's triad, which includes an increase in systolic blood pressure, widening pulse pressure (the difference between systolic and diastolic pressures), and bradycardia. An increased diastolic pressure with a narrowing pulse pressure is the opposite of the expected finding and is not a classic sign of significantly elevated ICP.
Choice D rationale
Confusion, restlessness, and a change in the level of consciousness or responsiveness (altered mental status) are often the earliest and most reliable signs of increasing intracranial pressure in a child. As ICP rises, cerebral perfusion pressure decreases, leading to cerebral ischemia and hypoxia, which directly impair cognitive function and alertness, making this the most critical initial alert sign.
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