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.

Jitteriness.

Acrocyanosis.

Hypotonia.

Temperature instability.

Answer and Explanation

Correct Answer : B,D,E

Choice A rationale:
Abdominal distention is not typically a sign of hypoglycemia in a newborn. It could be related to other factors such as feeding issues or gastrointestinal problems.
Choice B rationale:
Jitteriness can be a sign of hypoglycemia in a newborn as low blood sugar can cause nervous system hyperactivity.
Choice C rationale:
Acrocyanosis, or bluish discoloration of the hands and feet, is common in newborns and is not typically a sign of hypoglycemia.
Choice D rationale:
Hypotonia, or decreased muscle tone, can be a sign of hypoglycemia in a newborn as low blood sugar can affect muscle function.
Choice E rationale:
Temperature instability can be a sign of hypoglycemia in a newborn as low blood sugar can affect the body’s ability to regulate temperature.

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Correct Answer is A

Explanation

Choice A rationale:
Poor feeding is a common manifestation in newborns of mothers who used methadone during pregnancy.
Choice B rationale:
A weak cry is not specifically associated with methadone use during pregnancy.
Choice C rationale:
An absent Moro reflex is not specifically associated with methadone use during pregnancy.
Choice D rationale:
A respiratory rate of 30/min is within the normal range for a newborn (30-60 breaths per minute) and does not indicate methadone exposure.

A. Depressed anterior fontanel. B. Uneven gluteal skinfolds. C. Epicanthal folds. D. Facial asymmetry.

Correct Answer is D

Explanation

Choice A rationale:
A depressed anterior fontanel is not typically caused by forceps-assisted birth. It can indicate dehydration or intracranial pressure.
Choice B rationale:
Uneven gluteal skinfolds could suggest developmental dysplasia of the hip, not a forceps injury.
Choice C rationale:
Epicanthal folds are a normal characteristic in many populations and are not related to birth injuries.
Choice D rationale:
Facial asymmetry can occur due to pressure from the forceps on the facial nerves during delivery.

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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.).

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is assessing the newborn of a client who reports methadone use during pregnancy. The nurse should expect the newborn to exhibit which of the following manifestations?

Correct Answer is A

Explanation

A nurse is assessing a newborn who was born via a forceps-assisted birth. Which of the following findings should the nurse identify as an injury caused by the forceps?

Correct Answer is D

Explanation

A nurse is caring for a client who is postpartum and has a perineal laceration. Which of the following findings places the client at risk for delayed wound healing?

A nurse is caring for a client who is in labor and has a spontaneous rupture of membranes. The nurse notes that the umbilical cord is protruding from the client's vagina. After calling for help, which of the following actions should the nurse take first?

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