A nurse is assessing a newborn whose mother had gestational diabetes. Which of the following findings should the nurse identify as a manifestation of hypoglycemia?
Hypertonia.
Jitteriness.
Acrocyanosis.
Generalized petechiae.
The Correct Answer is B
Choice A rationale:
Hypertonia (increased muscle tone) is not a manifestation of hypoglycemia in a newborn. Instead, hypotonia (decreased muscle tone) is more characteristic.
Choice B rationale:
This is the correct choice. Jitteriness is a common sign of hypoglycemia in a newborn. It may be accompanied by other symptoms like poor feeding, tremors, and irritability.
Choice C rationale:
Acrocyanosis (bluish discoloration of the hands and feet) is a normal finding in newborns and is not specifically associated with hypoglycemia.
Choice D rationale:
Generalized petechiae (small red or purple spots on the skin caused by bleeding under the skin) are not indicative of hypoglycemia but may be associated with other medical conditions.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A rationale:
Administering oxytocin to the client via intravenous infusion is not appropriate when the nurse notes an umbilical cord protruding through the cervix. The priority is to relieve pressure on the cord to prevent fetal compromise, and administering oxytocin could worsen the situation.
Choice B rationale:
Applying oxygen at 2 L/min via nasal cannula is not the priority when an umbilical cord prolapse is detected. The focus should be on relieving pressure on the cord and changing the client's position to alleviate the compression.
Choice C rationale:
Preparing for insertion of an intrauterine pressure catheter is not appropriate when there is an umbilical cord prolapse. The immediate concern is the potential compromise of fetal blood flow, and addressing the cord prolapse takes precedence over any other interventions.
Choice D rationale:
Assisting the client into the knee-chest position is the correct action when an umbilical cord prolapse is observed during a vaginal exam. This position helps to alleviate pressure on the cord by moving the presenting part of the fetus off the cord and can prevent further fetal distress until more definitive interventions can be performed.
Correct Answer is A
Explanation
Choice A rationale:
Placing the newborn under a radiant heat warmer is used to prevent cold stress. Newborns are at risk of losing body heat rapidly, and cold stress can lead to various complications, including respiratory distress, hypoglycemia, and metabolic acidosis. The radiant heat warmer helps maintain the baby's body temperature within the normal range, promoting overall stability and reducing the risk of cold-related issues.
Choice B rationale:
The nurse should not choose choice B, "Respiratory depression,” as the action used to prevent. Placing the newborn under a radiant heat warmer does not specifically target respiratory depression. Respiratory depression in newborns may be related to various factors, such as anesthesia exposure during delivery or certain medications, and it requires appropriate monitoring and management rather than just heat regulation.
Choice C rationale:
The nurse should not choose choice C, "Thermogenesis,” as the action used to prevent. Thermogenesis refers to the generation of heat in the body, which is essential for maintaining body temperature. While the radiant heat warmer indirectly supports thermogenesis by preventing heat loss, the main purpose of using the warmer is to prevent cold stress, as stated in choice A.
Choice D rationale:
The nurse should not choose choice D, "Tachycardia,” as the action used to prevent. Tachycardia refers to an abnormally fast heart rate, and the use of a radiant heat warmer does not specifically target this condition. The purpose of the warmer, as explained earlier, is to maintain the baby's body temperature and prevent cold stress, not to address tachycardia.
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