A nurse is assessing a newborn whose mother had gestational diabetes mellitus. The nurse should monitor for which of the following findings as a manifestation of hypoglycemia?
Abdominal distention.
Petechiae.
Increased muscle tone.
Jitteriness.
The Correct Answer is D
Choice A rationale:
Abdominal distention is not a typical manifestation of hypoglycemia in a newborn. Instead, it can be associated with gastrointestinal issues or other conditions affecting the abdominal organs.
Choice B rationale:
Petechiae are small, pinpoint purple or red spots that appear on the skin due to broken capillaries. They are not related to hypoglycemia and can be caused by various factors such as blood clotting disorders or infections.
Choice C rationale:
Increased muscle tone is not typically associated with hypoglycemia in a newborn. Instead, hypoglycemic babies may exhibit decreased muscle tone, lethargy, and poor feeding.
Choice D rationale:
Jitteriness is a common manifestation of hypoglycemia in newborns. It is characterized by rhythmic tremors, often involving the face and extremities. This occurs because the brain relies heavily on glucose for energy, and low blood sugar levels can affect neurological function, leading to jitteriness. Prompt intervention is necessary to prevent further complications.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
The correct answer is choice d. “The nurse should measure the newborn’s muscle tone when assigning an Apgar score.”
Choice A rationale:
The Apgar score is determined at 1 and 5 minutes after birth, not at 2 and 7 minutes.
Choice B rationale:
An Apgar score of 8 indicates that the newborn is in good health, not severe distress. Scores of 7-10 are considered normal.
Choice C rationale:
Resuscitation efforts should not be delayed until the first Apgar score is obtained. Immediate resuscitation is initiated if needed, regardless of the Apgar score.
Choice D rationale:
Muscle tone is one of the five criteria assessed in the Apgar score, along with appearance, pulse, grimace, and respiration.
Correct Answer is C
Explanation
Choice A rationale:
Increased fetal movement is a positive sign during pregnancy and indicates the well-being of the baby. It is not a concern and does not require reporting.
Choice B rationale:
Increased urinary output may be expected in a client receiving magnesium sulfate due to its diuretic effects. This finding is not alarming and does not require immediate reporting unless it is associated with other concerning symptoms.
Choice C rationale:
Increased muscle weakness is a potential side effect of magnesium sulfate administration. It is important to monitor the client for signs of magnesium toxicity, and increased muscle weakness should be reported promptly as it may indicate the need for adjustments in the dosage or administration of the medication.
Choice D rationale:
Increased respiratory rate is not typically associated with magnesium sulfate use and is unlikely to be a concerning finding in this context. However, it's always essential to monitor respiratory status, but it may not be specifically related to the magnesium sulfate treatment.
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