A nurse is assessing a newborn who has hypoglycemia due to perinatal asphyxia.
Which of the following findings should the nurse expect? (Select all that apply.)
Irregular respirations
Cyanosis
Apnea
Eye-rolling
Lethargy
Correct Answer : A,C,D,E
The correct answer is choice A, C, D, and E. Hypoglycemia due to perinatal asphyxia can cause various neurological signs in the newborn, such as irregular respirations, apnea, eye-rolling, and lethargy.
These signs indicate inadequate oxygenation and glucose delivery to the brain. Cyanosis is not a specific sign of hypoglycemia, but rather a sign of poor oxygenation that can occur due to other causes.
Therefore, choice B is wrong.
Choice A is correct because irregular respirations can result from hypoglycemia due to perinatal asphyxia. Hypoglycemia can impair the respiratory center in the brainstem and cause irregular breathing patterns.
Choice C is correct because apnea can result from hypoglycemia due to perinatal asphyxia.
Apnea is defined as a pause in breathing
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
The correct answer is choice A.Factor II, also known as prothrombin, is one of the coagulation factors that are activated by vitamin K.Vitamin K is a cofactor for the carboxylation of specific glutamic acid groups in coagulation factors II, VII, IX, and X.
This process is essential for the activation of these factors in the coagulation cascade.
Choice B is wrong because factor V is not a vitamin K-dependent coagulation factor.
Factor V is activated by thrombin and acts as a cofactor for factor Xa in the conversion of prothrombin to thrombin.
Choice C is wrong because factor VIII is not a vitamin K-dependent coagulation factor.
Factor VIII is activated by thrombin and acts as a cofactor for factor IXa in the activation of factor X.
Choice D is wrong because factor XI is not a vitamin K-dependent coagulation factor.
Factor XI is activated by factor XIIa and activates factor IX in the intrinsic pathway of coagulation.
Normal ranges for coagulation factors are:
• Factor II: 70-120% of normal activity
• Factor V: 50-150% of normal activity
• Factor VIII: 50-150% of normal activity
• Factor IX: 50-150% of normal activity
• Factor X: 70-140% of normal activity
• Factor XI: 70-150% of normal activity
Correct Answer is B
Explanation
The correct answer is choice B. Give the vaccine intramuscularly in the anterolateral thigh.
This is because the anterolateral thigh is the recommended site for intramuscular injections in infants less than 12 months of age.
It has a large muscle mass and minimal risk of injury to nerves or blood vessels.
Choice A is wrong because informed consent is not required for routine immunizations, unless the parent or guardian requests more information or declines the vaccine.
Choice C is wrong because hepatitis B immune globulin (HBIG) is only indicated for newborns whose mothers are hepatitis B surface antigen positive (HBsAg+), as they have a high risk of acquiring the infection from their mothers.
Choice D is wrong because there is no need to delay giving the vaccine until after breastfeeding is established.
Breastfeeding does not interfere with the vaccine’s effectiveness or safety, and it does not increase the risk of adverse reactions.
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