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:
Urinating 30 mL/hr is correct. This is within the normal urinary output range of 30 to 60 mL/hr, indicating effective voiding.
Choice B rationale:
Not feeling the urge to urinate is incorrect. This could indicate urinary retention, not effective voiding.
Choice C rationale:
A uterine fundus 2 cm above the umbilicus is incorrect. This is unrelated to the client’s ability to void effectively.
Choice D rationale:
A distended bladder upon palpation is incorrect. This could suggest urinary retention, not effective voiding.

A. Remove the diaphragm 2 to 4 hr after intercourse. B. Insert the diaphragm up to 6 hr before intercourse. C. Wash the diaphragm with detergent soap between uses. D. Apply a vaginal lubricant to the diaphragm prior to insertion.

Correct Answer is B

Explanation

Choice A rationale:
Removing the diaphragm 2 to 4 hours after intercourse is incorrect because the diaphragm should be left in place for at least 6 hours after intercourse to prevent pregnancy.
Choice B rationale:
Inserting the diaphragm up to 6 hours before intercourse is correct. This allows time for the spermicide to become effective.
Choice C rationale:
Washing the diaphragm with detergent soap between uses is incorrect. Detergent soap can degrade the material of the diaphragm.
Choice D rationale:
Applying a vaginal lubricant to the diaphragm prior to insertion is incorrect. Lubricants can interfere with the effectiveness of the spermicide.

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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 caring for a postpartum client who recently had an indwelling urinary catheter removed. Which of the following findings indicates that the client is able to void effectively?

Correct Answer is A

Explanation

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Correct Answer is B

Explanation

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