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A nurse is assessing a late preterm newborn. Which of the following manifestations is an indication of hypoglycemia?
- A. Hypertonia
- B. Increased feeding
- C. Hyperthermia
- D. Respiratory distress
Correct Answer: D
Rationale: Correct Answer: D - Respiratory distress
Rationale: Hypoglycemia in a late preterm newborn can lead to respiratory distress due to inadequate glucose supply to the brain, causing dysfunction in respiratory centers. This can manifest as tachypnea, grunting, nasal flaring, and retractions. Hypertonia, increased feeding, and hyperthermia are not specific signs of hypoglycemia in newborns.
Summary:
A: Hypertonia is not a typical manifestation of hypoglycemia in newborns.
B: Increased feeding is more likely to be seen in newborns with hunger cues, not necessarily indicative of hypoglycemia.
C: Hyperthermia is not a common sign of hypoglycemia in newborns.
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A nurse is caring for a postpartum client who is receiving heparin via a continuous IV infusion for thrombophlebitis in their left calf. Which of the following actions should the nurse take?
- A. Administer aspirin for pain.
- B. Maintain the client on bed rest.
- C. Massage the affected leg every 12 hr.
- D. Apply cold compresses to the affected calf.
Correct Answer: B
Rationale: Rationale: Choice B is correct because bed rest helps prevent further clot formation and reduces the risk of embolism. Movement can dislodge the clot. Aspirin (Choice A) can increase bleeding risk. Massaging (Choice C) can dislodge clots. Cold compresses (Choice D) can also increase bleeding risk and dislodge clots.
A nurse is assessing a late preterm newborn. Which of the following manifestations is an indication of hypoglycemia?
- A. Hypertonia
- B. Increased feeding
- C. Hyperthermia
- D. Respiratory distress
Correct Answer: D
Rationale: The correct answer is D: Respiratory distress. Hypoglycemia in a late preterm newborn can lead to respiratory distress due to inadequate glucose supply to the brain, causing neurologic dysfunction. Hypertonia (choice A) is more indicative of hypocalcemia. Increased feeding (choice B) is not a typical manifestation of hypoglycemia. Hyperthermia (choice C) is not directly related to hypoglycemia. In summary, respiratory distress is a key sign of hypoglycemia in a late preterm newborn, while the other choices are not specific indicators.
A nurse is planning care for a client who is in labor and is to have an amniotomy. Which of the following assessments should the nurse identify as the priority?
- A. O2 saturation
- B. Temperature
- C. Blood pressure
- D. Urinary output
Correct Answer: B
Rationale: The correct answer is B: Temperature. During an amniotomy, there is an increased risk of infection due to the introduction of bacteria into the uterine cavity. Monitoring the client's temperature is crucial to detect any signs of infection promptly. A sudden spike in temperature could indicate chorioamnionitis, a serious infection that can harm both the mother and the baby. O2 saturation (A), blood pressure (C), and urinary output (D) are important assessments but are not the priority in this situation. Monitoring O2 saturation is essential for fetal well-being but is not directly related to the amniotomy procedure. Blood pressure monitoring is significant for detecting any changes in maternal status, but infection assessment takes precedence in this case. Urinary output is essential for assessing hydration status and kidney function, but infection monitoring is more critical during an amniotomy.
A nurse is assessing a newborn 12 hr after birth. Which of the following manifestations should the nurse report to the provider?
- A. Acrocyanosis
- B. Transient strabismus
- C. Jaundice
- D. Caput succedaneum
Correct Answer: C
Rationale: The correct answer is C: Jaundice. Jaundice in a newborn within the first 24 hours of life can be indicative of pathological conditions such as hemolytic disease or liver dysfunction. The nurse should report this to the provider promptly for further evaluation and management. Acrocyanosis (A) and caput succedaneum (D) are common and normal findings in newborns. Transient strabismus (B) is also common and typically resolves on its own. Make sure to assess for any other concerning symptoms and report them as well.
A nurse is assessing a newborn who is 16 hr old. Which of the following findings should the nurse report to the provider?
- A. Substernal retractions
- B. Acrocyanosis
- C. Overlapping suture lines
- D. Head circumference 33 cm (13 in)
Correct Answer: A
Rationale: The correct answer is A: Substernal retractions. Substernal retractions in a newborn indicate respiratory distress and can be a sign of a serious issue such as respiratory distress syndrome. This finding requires immediate attention from the provider to assess and manage the newborn's respiratory status. Acrocyanosis (B) is a common finding in newborns and is not typically concerning. Overlapping suture lines (C) can be normal in newborns due to molding during birth. A head circumference of 33 cm (13 in) (D) falls within the normal range for a newborn and does not require immediate reporting.