The nurse collects client data and determines the newborn is most likely experiencing hypoglycemia as evidenced by which of the following?
Jitteriness.
Increased temperature.
Brisk reflexes.
Absence of a Moro reflex.
The Correct Answer is A
Choice A rationale
Hypoglycemia in a newborn, defined as a plasma glucose level typically below 40 to 50 mg/dL, starves the central nervous system of its primary energy source, glucose. This lack of fuel in the brain cells often presents with neurological symptoms. Jitteriness (or tremors) is a classic and early neurogenic sign of this metabolic disturbance, resulting from sympathetic nervous system activation.
Choice B rationale
Hypoglycemia typically results in an attempt by the body to conserve energy and may lead to poor peripheral perfusion and decreased metabolic rate, which often manifests as hypothermia (decreased temperature). Increased temperature (hyperthermia) is not a sign of hypoglycemia; instead, it is often associated with infection or environmental overheating.
Choice C rationale
Hypoglycemia causes central nervous system instability and depression, which generally results in a decrease in a newborn's reflexes and muscle tone (hypotonia), or can lead to lethargy and poor feeding. Therefore, brisk reflexes (hyperreflexia) are not a characteristic finding and would suggest other neurological or metabolic conditions.
Choice D rationale
The Moro reflex (or startle reflex) is a complex, primitive reflex that is present and intact in healthy newborns. While severe hypoglycemia can lead to generalized central nervous system depression, which could eventually suppress all reflexes, an absence of a Moro reflex is a more specific sign of a severe neurological injury or a congenital neurological disorder, not a typical early sign of hypoglycemia.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A rationale
Calcium is essential for fetal bone and tooth development, as well as for maternal skeletal integrity, muscle function, and blood clotting. Although crucial, an increase in calcium intake (normal recommended intake is 1000 mg/day for most pregnant women) is primarily aimed at skeletal and cellular health, not specifically at the physiological increase in maternal blood volume, which necessitates increased erythrocyte production and plasma volume.
Choice B rationale
Vitamin E is an important fat-soluble antioxidant that protects cell membranes from oxidative damage and plays a role in red blood cell (RBC) integrity. While it is necessary for overall maternal and fetal health, its primary function is not directly linked to the significant expansion of maternal plasma and erythrocyte mass, which is the physiological basis for the approximately 30% to 50% increase in maternal blood volume during pregnancy.
Choice C rationale
Vitamin D is a fat-soluble vitamin critical for intestinal absorption of calcium and phosphorus, thereby maintaining optimal bone mineralization and immune function. Although supplementation is often necessary, especially in those with limited sun exposure (normal range 20-50 ng/mL), its primary role is in calcium homeostasis and immune function, not as a direct substrate for the substantial increase in maternal plasma volume and red blood cell mass during gestation.
Choice D rationale
Iron is a fundamental component of the heme group in hemoglobin, which is crucial for oxygen transport by red blood cells (RBCs). The approximately 45% increase in maternal blood volume during pregnancy requires a substantial increase in RBC production (erythropoiesis) to prevent dilutional anemia. Therefore, increased iron intake (normal recommended intake 27 mg/day) is vital for the necessary synthesis of hemoglobin to support this physiologic increase in maternal erythrocyte volume.
Correct Answer is ["0.25"]
Explanation
Step 1 is to determine the volume needed using the formula: Volume = (Dose prescribed÷Concentration available). 0.5 mg÷ (1 mg / 0.5 mL).
Step 2 is to perform the division:. 0.5 × 0.5 mL.
Step 3 is to calculate the final volume:. 0.25 mL. The nurse should administer 0.25 mL.
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