TB-Chapter_09__The_Family_After_Birth

The nurse is assessing a newborn. What sign of hypoglycemia does the nurse record? a. Increased nasal mucus b. Increased temperature c. Active muscle movements d. High-pitched cry ANS: D There are many signs of hypoglycemia in the newborn. One is a high-pitched cry. DIF: Cognitive Level: Comprehension REF: Page 228 TOP: Signs of Hypoglycemia KEY: Nursing Process Step: Data Collection MSC: NCLEX: Physiological Integrity: Reduction of Risk 2. What would the nurse expect to find when assessing the fundus of the uterus immediately after delivery? a. Well-contracted with its upper border at or just below the umbilicus b. Well-contracted with its upper border three or four fingerbreadths above the umbilicus c. Relaxed with its upper border level with the umbilicus d. Relaxed with its upper border two or three fingerbreadths below the umbilicus ANS: A Immediately after the placenta is expelled, the uterine fundus can be felt as a firm mass, about the size of a grapefruit, at the level of the umbilicus. DIF: Cognitive Level: Comprehension REF: Page 209 TOP: Fundus Assessment KEY: Nursing Process Step: Data Collection MSC: NCLEX: Physiological Integrity: Physiological Adaptation