April 2, 2024 – NCLEX Practice Questions

NCLEX Practice Question

April 02 , 2024

Tuesday

A diabetic woman has a precipitous delivery in the emergency department. Which initial neonate assessment finding is not expected and is a priority for nursing response?

Apgar score of 7 at 1 minute
Apical heart rate of 160 / min
Circumoral duskiness
Jitteriness
 
  • Option 4
Infants of diabetic mothers are at risk of hypoglycemia and hypocalcemia. The transitional time is especially high risk for hypoglycemia as the fetus produced high levels of insulin in response to the high levels of circulating maternal glucose. The insulin level for a diabetic mother’s neonate remains higher than normal in the first few hours of extrauterine life, making the neonate at risk for hypoglycemia. Hypoglycemia in a newborn is considered a blood glucose level <40 mg/dL. Symptoms of hypoglycemia include jitteriness, irritability, hypotonia, apnea, lethargy, and temperature instability.
  • (Option 1)
An Apgar score of 7-10 indicates a stable status. Apgar scores are normally assessed at 1 minute and 5 minutes after birth. If the 5 minute score is <7, additional scores should be assigned every 5 minutes up to 20 minutes.
  • (Option 2)
Normal neonatal heart rate is 120-160 beats/min. The rate can increase to 180/min with crying and fall as low as 100/min during sleep. Sustained tachycardia (>160 beats/min) for >10 minutes indicates possible sepsis, respiratory distress, or congenital heart abnormality. Bradycardia indicates possible sepsis, increased intracranial pressure, or hypoxia. The neonate’s heart rate should be assessed by taking an apical rate for a full minute (noting the rate and rhythm).
  • (Option 3)
Circumoral cyanosis is a benign localized transient cyanosis around the mouth during the transition period. If it persists, it may be related to a cardiac anomaly.
  • Educational objective:
Infants of diabetic mothers are at high risk for hypoglycemia in the transition period. A common symptom of hypoglycemia in a newborn is jitteriness

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NCLEX Practice Question
NCLEX Practice Question

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