A nurse is caring for a newborn who has hyperthermia. Which of the following manifestations should the nurse expect?
Hypoglycemia
Flushed skin
Acrocyanosis
Respiratory rate 40/min
The Correct Answer is B
A. Hypoglycemia: Hyperthermia in a newborn is not directly linked to hypoglycemia. However, overheating can lead to increased metabolism, and in some cases, it could exacerbate metabolic issues, but it is not a primary cause of hypoglycemia.
B. Flushed skin: Flushed skin is a common sign of hyperthermia. When the newborn's body temperature rises above the normal range, the skin may appear red or flushed as a result of the body’s attempt to regulate heat through increased blood flow.
C. Acrocyanosis: Acrocyanosis is typically a sign of cold stress, not hyperthermia. It refers to a bluish color of the hands and feet due to poor circulation and is more commonly seen when a newborn is cold.
D. Respiratory rate 40/min: A respiratory rate of 40/min is within the normal range for a newborn. An elevated respiratory rate would be expected if the newborn was in distress or overheated, but a rate of 40/min is normal and does not specifically indicate hyperthermia.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Initiate a continuous infusion of 0.9% sodium chloride: The first priority in managing HHS is fluid resuscitation. Dehydration is a major concern and the nurse should initiate a continuous infusion of 0.9% sodium chloride to restore circulating volume and correct electrolyte imbalances.
B. Evaluate the client's understanding of diabetes management: While education about diabetes management is important, it is not the first priority in an emergency situation. The immediate focus should be on stabilizing the client's condition.
C. Administer potassium supplements: Potassium supplementation may be needed later as part of treatment for HHS, especially after the initial fluid resuscitation, as potassium can shift out of cells with insulin treatment. However this is not the first action.
D. Check for improvements in the client's level of consciousness: Monitoring the client's level of consciousness is important, but addressing the underlying dehydration and hyperglycemia through fluid resuscitation should be the first priority in stabilizing the client.
Correct Answer is B
Explanation
A. Eat a low-residue diet: A low-residue diet, which involves limiting fiber can contribute to constipation. To avoid constipation, a higher fiber intake is generally encouraged.
B. Increase daily water intake: Increasing water intake is one of the most effective ways to help prevent constipation, especially after surgery. Adequate hydration softens stool and helps promote regular bowel movements.
C. Take a daily laxative to soften stools: While laxatives may be used in certain cases, they are not recommended for long-term use as they can lead to dependence. The goal is to manage bowel health through diet, hydration, and activity, rather than relying on medications.
D. Drink cold beverages to increase peristalsis: Drinking cold beverages does not directly increase peristalsis. Hydration is important, but the temperature of the beverages is not a primary factor in preventing constipation.
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