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
Choice A rationale:
The nurse does not need to obtain a sample of the discharge for laboratory testing at this point. Yellow discharge after circumcision is common and generally not a cause for immediate concern. Laboratory testing is not necessary for routine circumcision care.
Choice B rationale:
Applying povidone-iodine solution twice daily to the circumcision site is not recommended in this situation. Povidone-iodine may cause irritation and delay the natural healing process.
Generally, no specific cleaning solution is required for circumcision care unless otherwise indicated by a healthcare provider.
Choice C rationale:
Wiping the discharge away gently with a washcloth and warm water for the next 48 hours is not the most appropriate action. The circumcision site should be kept clean and dry, but actively wiping away the discharge may cause irritation and disrupt the natural healing process.
Correct Answer is C
Explanation
Choice A rationale:
The nurse should not include the information about beginning Kegel exercises 6 to 7 weeks after delivery because Kegel exercises are pelvic floor exercises that help improve bladder control and should be started earlier, immediately after childbirth. Delaying the exercises for 6 to 7 weeks could result in weaker pelvic floor muscles and potentially exacerbate postpartum urinary issues.
Choice B rationale:
The nurse should not include the information that the client doesn't need to use birth control if exclusively breastfeeding. While exclusive breastfeeding can provide some natural contraceptive effect, it is not a reliable method, and there is still a risk of pregnancy during the postpartum period. The nurse should advise the client to use appropriate birth control methods to prevent unintended pregnancies.
Choice C rationale:
This is the correct answer. The nurse should include information about the client's breasts becoming firm and tender 3 to 5 days after delivery. This is a normal physiological response known as engorgement, which occurs as the breasts prepare for breastfeeding.
Choice D rationale:
The nurse should not inform the client that her bleeding will remain bright red for the next 6 to 8 weeks. While some postpartum bleeding is normal (known as lochia), the color and amount of bleeding change over time. Initially, it is bright red and gradually transitions to a lighter color over the following weeks.
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