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.

Nursing Test Bank

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

Correct Answer is A

Explanation

A. Previous cervical cerclage:

Cervical cerclage is a surgical procedure performed to reinforce the cervix in women with a history of cervical insufficiency or cervical incompetence. Cervical insufficiency is a condition where the cervix begins to dilate prematurely, leading to an increased risk of preterm birth. By placing a cervical cerclage, the risk of preterm delivery due to cervical insufficiency is reduced. Therefore, a history of previous cervical cerclage indicates an increased risk for preterm delivery in subsequent pregnancies.

B. Previous delivery of a newborn weighing 2.5 kg (5.5 lb):

A newborn weighing 2.5 kg (5.5 lb) at birth suggests that the infant was small for gestational age (SGA). While SGA infants may be at risk for various complications, such as intrauterine growth restriction (IUGR), it does not directly indicate an increased risk for preterm delivery in subsequent pregnancies. Therefore, this choice is not indicative of preterm delivery risk.

C. Previous reactive non-stress test:

A reactive non-stress test (NST) is a reassuring finding during pregnancy and indicates that the fetus is receiving adequate oxygenation and is not under distress. While the absence of a reactive NST might indicate fetal compromise and the need for further evaluation, a previous reactive NST does not necessarily indicate an increased risk for preterm delivery.

D. Previous delivery at 37 weeks gestation:

A delivery at 37 weeks gestation is considered full-term and does not indicate an increased risk for preterm delivery. In fact, delivering at 37 weeks is within the normal range of gestational age and is not typically associated with preterm birth risk factors. Therefore, this choice does not indicate an increased risk for preterm delivery.

A. Irregular contractions of 10 to 20 seconds in duration that are not felt by the client B. An increase in fetal heart rate to 150/min above the baseline of 140/min lasting 10 seconds in response to fetal movement within a 40-min testing period C. No late decelerations in the fetal heart rate noted with three uterine contractions of 60 seconds in duration within a 10-min testing period D. Three fetal movements perceived by the client in a 20-min testing period

Correct Answer is A

Explanation

A. Irregular contractions of 10 to 20 seconds in duration that are not felt by the client.

Irregular contractions alone are not necessarily concerning. However, if they are not felt by the client, it may indicate decreased fetal movement. Further evaluation is needed to ensure the baby’s well-being.

B. An increase in fetal heart rate to 150/min above the baseline of 140/min lasting 10 seconds in response to fetal movement within a 40-min testing period.

An increase in fetal heart rate to 150/min above the baseline of 140/min lasting 10 seconds in response to fetal movement within a 40-min testing period:This finding is reassuring.A reactive NST (with accelerations in FHR) indicates that the baby is healthy and responsive to moveme.

C. No late decelerations in the fetal heart rate noted with three uterine contractions of 60 seconds in duration within a 10-min testing period.

The absence of late decelerations during uterine contractions is a positive finding during an NST. Late decelerations, which occur after the peak of the contraction, can indicate uteroplacental insufficiency and fetal hypoxia. Therefore, not observing late decelerations during contractions is reassuring and does not typically necessitate further testing.

D. Three fetal movements perceived by the client in a 20-min testing period.

Perceiving fetal movements during the testing period is generally considered reassuring during an NST. Fetal movements are indicative of fetal well-being and activity. Therefore, this finding is typically interpreted as a positive sign and does not typically require further evaluation during the NST.

A. Irregular contractions of 10 to 20 seconds in duration that are not felt by the client.
Irregular contractions of short duration that are not perceived by the client are not typically concerning during a nonstress test (NST). The primary focus of an NST is to assess fetal heart rate patterns in response to fetal movement and uterine activity. As long as these contractions do not lead to decelerations or other signs of fetal distress, they are not usually indicative of a problem.

B. An increase in fetal heart rate to 150/min above the baseline of 140/min lasting 10 seconds in response to fetal movement within a 40-min testing period.
This is the correct answer. While fetal heart rate accelerations in response to fetal movement are typically reassuring during an NST, an acceleration of 150 beats per minute above the baseline heart rate, lasting 10 seconds, could indicate fetal distress or compromise. Such a significant increase may suggest that the fetus is having difficulty compensating for stress or may be experiencing hypoxia, necessitating further evaluation.

C. No late decelerations in the fetal heart rate noted with three uterine contractions of 60 seconds in duration within a 10-min testing period.
The absence of late decelerations during uterine contractions is a positive finding during an NST. Late decelerations, which occur after the peak of the contraction, can indicate uteroplacental insufficiency and fetal hypoxia. Therefore, not observing late decelerations during contractions is reassuring and does not typically necessitate further testing.

D. Three fetal movements perceived by the client in a 20-min testing period.
Perceiving fetal movements during the testing period is generally considered reassuring during an NST. Fetal movements are indicative of fetal well-being and activity. Therefore, this finding is typically interpreted as a positive sign and does not typically require further evaluation during the NST.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

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 reviewing the history of a client who is pregnant. Which of the following clinical data indicates the client is at risk for preterm delivery?

Correct Answer is A

Explanation

A nurse is assessing the results of a nonstress test for an antepartal client at 35 weeks of gestation. Which of the following findings should indicate to the nurse the need for further diagnostic testing?

Correct Answer is A

Explanation

A nurse is caring for a client who is experiencing infertility and is requesting in vitro fertilization. Which of the following information should the nurse provide to the client?

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?

A postpartum nurse is caring for a client and their newborn. Which of the following observations should indicate to the nurse that the client is in the taking-in phase of maternal role attainment?

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.)

A nurse on the postpartum unit is caring for four clients. For which of the following clients should the nurse notify the provider?

A nurse is assessing a client who is 1 hr postpartum. Which of the following findings should the nurse report to the provider?

A nurse is preparing to perform a heel stick on a newborn who has a prescription for a total serum bilirubin. Which of the following actions should the nurse take?

A nurse is planning care for a client who is 1 hr postpartum and has preeclampsia without severe features. Which of the following actions should the nurse plan to take?