A nurse is assessing a newborn who is 2 hr old. Which of the following findings is an indication of hypoglycemia? (Select all that apply.)

Abdominal distention

Acrocyanosis

Hypotonia

Jitteriness

Temperature instability

Answer and Explanation

Correct Answer : C,D,E

A. Abdominal distention:

Explanation: Abdominal distention is more commonly associated with issues such as gas or gastrointestinal discomfort. It is not a typical sign of hypoglycemia.

B. Acrocyanosis:

Explanation: Acrocyanosis, a bluish discoloration of the extremities, is a common finding in newborns and is often unrelated to hypoglycemia. It is generally considered a normal response in the early hours or days of life.

C. Hypotonia:

Explanation: Hypotonia, or decreased muscle tone, can be associated with hypoglycemia. It may present as limpness or weakness in the newborn.

D. Jitteriness:

Explanation: Jitteriness, which is tremors or shakiness, can be a sign of hypoglycemia in a newborn. It is a result of the central nervous system responding to low blood glucose levels.

E. Temperature instability:

Explanation: Temperature instability, such as difficulty maintaining a stable body temperature, can be indicative of hypoglycemia. The newborn's ability to regulate temperature may be affected.

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Correct Answer is B

Explanation

A. Postpartum hemorrhage: Effacement and dilation relate to the progress of labor, not postpartum hemorrhage. Postpartum hemorrhage is excessive bleeding that occurs after childbirth, typically within 24 hours, and can have various causes unrelated to cervical dilation.

B. Incompetent cervix: Incompetent cervix, also known as cervical insufficiency, refers to the premature and painless dilation of the cervix during the second trimester of pregnancy. It is not directly related to the dilation mentioned in the scenario. However, it is possible that the client may have misunderstood the timing of contractions, and the nurse should assess for other signs of cervical insufficiency.

C. Hyperemesis gravidarum: Hyperemesis gravidarum is severe nausea and vomiting during pregnancy, which can lead to dehydration and electrolyte imbalances. It is not directly related to cervical dilation or effacement.

D. Ectopic pregnancy: An ectopic pregnancy is a pregnancy that occurs outside the uterus, usually in the fallopian tube. Cervical dilation and effacement are not associated with ectopic pregnancies.

A. Use fingers to exert upward pressure on the presenting part B. Administer a tocolytic medication C. Wrap the cord in a sterile towel and moisten with warm sterile normal saline D. Apply oxygen via facemask to the client

Correct Answer is A

Explanation

A. Use fingers to exert upward pressure on the presenting part

The priority in the case of a prolapsed umbilical cord is to relieve pressure on the cord to maintain blood flow to the fetus. The nurse should use sterile-gloved fingers to lift the presenting part of the fetus off the prolapsed cord. This action helps prevent compression of the umbilical cord, which could lead to fetal hypoxia and distress.

B. Administer a tocolytic medication: Tocolytic medications are used to inhibit uterine contractions. While tocolytics might be used in certain situations, the immediate concern with a prolapsed cord is to relieve pressure on it to maintain fetal blood flow.

C. Wrap the cord in a sterile towel and moisten with warm sterile normal saline: While covering the cord with a sterile towel and moistening it can help prevent drying and protect the cord, it is not the first priority. The primary concern is relieving pressure on the cord to prevent fetal compromise.

D. Apply oxygen via facemask to the client: Oxygen administration is important in managing fetal distress, but it is not the first action to take in the case of a prolapsed umbilical cord. The priority is to relieve pressure on the cord to maintain fetal oxygenation.

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A nurse is assessing a newborn who is 2 hr old. Which of the following findings is an indication of hypoglycemia? (Select all that apply.)

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