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 ["B","C","F"]

Explanation

A. Thromboembolism:

Thromboembolism refers to the formation of blood clots (thrombi) that break loose and travel through the bloodstream, potentially causing blockages in blood vessels (embolism). While thromboembolism is a risk in pregnancy, especially in individuals with risk factors such as obesity or a history of thromboembolic events, there are no specific indications in the scenario provided that suggest an increased risk of thromboembolism for this client.

B. Electrolyte imbalance:

The client's persistent nausea, vomiting, and ketonuria indicate significant dehydration and electrolyte imbalances. Dehydration can lead to imbalances in electrolytes such as potassium, sodium, and chloride, which are essential for proper bodily function. Laboratory findings of low potassium (hypokalemia) and elevated blood urea nitrogen (BUN) support the presence of electrolyte imbalances. These imbalances can have serious consequences for both the client and the fetus, including cardiac arrhythmias, muscle weakness, and metabolic disturbances.

C. Fetal growth restriction:

Hyperemesis gravidarum, characterized by severe nausea and vomiting leading to dehydration and weight loss, is associated with an increased risk of fetal growth restriction. Inadequate maternal nutrition and dehydration can compromise fetal growth and development, potentially leading to a smaller-than-expected size for gestational age. The client's weight loss and ketonuria further support the possibility of fetal growth restriction due to insufficient nutrient intake and placental perfusion.

D. Polyhydramnios:

Polyhydramnios refers to an excess of amniotic fluid surrounding the fetus in the uterus. While hyperemesis gravidarum and dehydration can lead to maternal complications, such as electrolyte imbalances and fetal growth restriction, they are not typically associated with an increased risk of polyhydramnios. Polyhydramnios is more commonly linked to fetal anomalies, maternal diabetes, or fetal conditions that affect swallowing or fluid regulation, none of which are evident in the provided scenario.

E. Gestational diabetes mellitus:

Gestational diabetes mellitus (GDM) is a condition characterized by high blood sugar levels during pregnancy. While GDM can lead to various complications for both the mother and the fetus, including macrosomia (large birth weight), birth injuries, and neonatal hypoglycemia, there are no indications in the scenario provided that suggest an increased risk of GDM for this client.

F. Spontaneous abortion:

Hyperemesis gravidarum, with severe nausea, vomiting, and weight loss, is associated with an increased risk of spontaneous abortion or miscarriage. Dehydration, electrolyte imbalances, and maternal malnutrition can compromise maternal and fetal well-being, potentially leading to pregnancy loss. Therefore, the client is at an increased risk of spontaneous abortion due to the severity of her symptoms and the impact on her overall health and pregnancy.

A. Administer oxygen via face mask at 10 L/min. B. Collect hemoglobin and hematocrit levels. C. Prepare the client to receive a plasma expander. D. Insert an indwelling urinary catheter.

Correct Answer is B

Explanation

A. Administer oxygen via face mask at 10 L/min:

Administering oxygen can help improve tissue oxygenation and prevent hypoxia, which is critical in managing a client at risk of hypovolemic shock. However, while oxygenation is important, it may not directly address the underlying cause of the excessive bleeding. Therefore, while oxygen may be necessary, it is not the most immediate action required to address the potential cause of the hemorrhage.

B. Collect hemoglobin and hematocrit levels:

Collecting hemoglobin and hematocrit levels is essential for assessing the extent of blood loss and the client's hemodynamic status. This information will help determine the severity of the situation and guide further management and interventions, such as blood transfusion if indicated. Since postpartum hemorrhage is a leading cause of maternal mortality, prompt assessment of blood loss is crucial in guiding appropriate interventions to prevent further complications.

C. Prepare the client to receive a plasma expander:

Plasma expanders may be administered to help restore circulating blood volume in cases of hypovolemic shock due to significant blood loss. However, before initiating plasma expander administration, it is essential to assess the client's hemoglobin and hematocrit levels to determine the severity of blood loss and guide appropriate fluid resuscitation strategies. Therefore, preparing the client to receive a plasma expander would come after assessing the extent of blood loss through laboratory values.

D. Insert an indwelling urinary catheter:

Inserting an indwelling urinary catheter may be necessary to monitor urinary output, which is an important indicator of renal perfusion and overall fluid status. However, while urinary catheterization is important for assessing renal function and fluid balance, it is not the most immediate action required to address the potential cause of the hemorrhage. Assessing blood loss through laboratory values and initiating appropriate interventions to manage postpartum hemorrhage take precedence over urinary catheterization in this scenario.

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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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