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 D

Explanation

A. Restrict daily oral fluid intake: Restricting oral fluid intake is not generally recommended unless there is a specific medical indication. Adequate hydration is important, especially postpartum, and fluid restriction may not be appropriate unless there are specific reasons to do so.

B. Administer an IV bolus of lactated Ringer’s: In a client with preeclampsia without severe features, intravenous fluid bolus administration is not the primary intervention. Fluid management is important, but it is typically done judiciously based on the client's specific needs, not as a routine IV bolus.

C. Obtain a prescription for misoprostol: Misoprostol is a medication that is sometimes used to prevent or treat postpartum hemorrhage but is not a routine intervention for a client with preeclampsia without severe features. The focus in preeclampsia management is on blood pressure control and monitoring for signs of worsening disease.

D. Assess for edema: This is the correct action. Assessing for edema is an important component of monitoring a client with preeclampsia. While edema is a common symptom in pregnancy, excessive or sudden-onset edema may be an indication of worsening preeclampsia.

A. Report of perineal pain as 0 on a scale of 0 to 10 B. Report of relief of pruritus C. Increased urinary output D. Blood pressure 110/70 mm Hg

Correct Answer is D

Explanation

A. Report of perineal pain as 0 on a scale of 0 to 10: Perineal pain is more directly related to the effects of spinal anesthesia rather than fluid status. A decrease in perineal pain would be expected after the administration of spinal anesthesia, but it may not specifically indicate the effectiveness of the IV bolus.

B. Report of relief of pruritus: Pruritus (itching) is a common side effect of spinal anesthesia. Relief of pruritus can be expected after the administration of spinal anesthesia, but it is not a direct indicator of the effectiveness of the IV bolus.

C. Increased urinary output: Increased urinary output may indicate improved renal perfusion or fluid balance but is not a specific indicator of the effectiveness of the IV bolus in the context of spinal anesthesia for labor.

D. Blood pressure 110/70 mm Hg: This is the correct answer. Blood pressure is an important parameter to monitor, especially after administering an IV bolus of fluids. A blood pressure within the normal range (110/70 mm Hg) suggests that the bolus has been effective in addressing any hypovolemia or dehydration.

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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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Naxlex Comprehensive Predictor Exams

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Explanation

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Explanation

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