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

Temperature instability

Hypotonia

Jitteriness

Answer and Explanation

Correct Answer : D,E

A. Abdominal distention:

Abdominal distention is not typically associated with hypoglycemia in newborns. It may be caused by other factors such as swallowed air during feeding or gastrointestinal issues.

B. Acrocyanosis:

Acrocyanosis, which is the blueness of the hands and feet, is a common finding in newborns and is not specific to hypoglycemia. It is often a result of the newborn's immature circulatory system.

C. Temperature instability:

Temperature instability, including hypothermia or hyperthermia, can occur in newborns for various reasons, but it is not specific to hypoglycemia.

D. Hypotonia:

Hypotonia, or decreased muscle tone, can be a sign of hypoglycemia in newborns. It may present as decreased activity, floppy movements, or poor feeding.

E. Jitteriness

Jitteriness, which is characterized by tremors or shaky movements, is a common manifestation of hypoglycemia in newborns. It is often observed when the newborn's blood glucose levels are low and can be a significant sign of hypoglycemia.

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Correct Answer is C

Explanation

A. The client cleans the perineum with a squeeze bottle after urinating:

This action is a recommended postpartum hygiene practice. Using a squeeze bottle filled with warm water to gently clean the perineum after urinating helps to promote cleanliness and prevent infection. It is important to maintain good hygiene in the perineal area to support wound healing and reduce the risk of complications.

B. The client's perineal suture line is well-approximated:

A well-approximated perineal suture line indicates that the edges of the laceration have been properly aligned and closed with sutures. This is an essential aspect of wound management, as it promotes healing by primary intention. When the wound edges are closely aligned and secured, it reduces the risk of infection and supports optimal healing.

C. The client is changing the perineal pad once daily:

Changing the perineal pad only once daily is a suboptimal practice that can contribute to delayed wound healing. Postpartum clients with perineal lacerations should change their perineal pads frequently, at least every 4 to 6 hours, to maintain cleanliness and prevent excessive moisture buildup, which can increase the risk of infection and hinder wound healing.

D. The client is using witch hazel pads on the perineum:

Witch hazel pads are commonly used for comfort and to alleviate swelling and discomfort in the perineal area after childbirth. While witch hazel pads can provide symptomatic relief, they are not typically associated with delayed wound healing when used appropriately. However, it's essential to ensure that the perineal area remains clean and dry to promote optimal wound healing and prevent complications.

A. Place a cool cloth at the site for 15 min before the procedure. B. Apply an alcohol pad to the site after the procedure. C. Puncture the lateral side of the heel for the procedure. D. Select a 21-gauge needle to perform the procedure.

Correct Answer is C

Explanation

A. Place a cool cloth at the site for 15 min before the procedure:

Placing a cool cloth at the site before the procedure is not typically done for a heel stick in newborns. In fact, applying cold to the site can cause vasoconstriction, which may make it more difficult to obtain an adequate blood sample. Additionally, cooling the area can potentially lead to discomfort for the newborn. Therefore, this action is not recommended and would not be appropriate in this scenario.

B. Apply an alcohol pad to the site after the procedure:

While alcohol pads are commonly used for disinfection before certain procedures, they are not typically used after a heel stick to obtain a blood sample for a total serum bilirubin test. Alcohol can interfere with bilirubin testing by altering the bilirubin levels in the blood, leading to inaccurate results. Therefore, applying an alcohol pad after the procedure is not recommended, particularly for bilirubin testing.

C. Puncture the lateral side of the heel for the procedure:

When performing a heel stick on a newborn, it is important to choose the appropriate site for puncture. The lateral side of the heel is preferred over the medial side because it has fewer nerves and blood vessels, reducing the risk of complications and discomfort for the newborn. Puncturing the lateral side also allows for a more controlled and successful blood draw. Therefore, this choice is the most appropriate for obtaining a blood sample for a total serum bilirubin test.

D. Select a 21-gauge needle to perform the procedure:

The choice of needle gauge for a heel stick in a newborn depends on various factors, including the size of the newborn's heel and the desired blood flow rate. However, a 21-gauge needle is relatively large and may cause more pain and tissue trauma compared to smaller gauge needles, especially in newborns. Smaller gauge needles, such as 23 or 25 gauge, are typically preferred for heel sticks in newborns to minimize discomfort and trauma to the tissue. Therefore, selecting a 21-gauge needle may not be the most appropriate choice for this procedure.

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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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Correct Answer is C

Explanation

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Correct Answer is C

Explanation

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