A nurse is caring for a newborn and observes signs of diaphoresis, jitteriness, and lethargy.
Which of the following actions should the nurse take?
Monitor the newborn's blood pressure.
Obtain blood glucose by heel stick.
Place the newborn in a radiant warmer.
Initiate phototherapy.
The Correct Answer is B
Choice A rationale
Monitoring the newborn's blood pressure does not directly address symptoms like diaphoresis, jitteriness, and lethargy. These symptoms indicate an immediate need to check blood glucose levels for hypoglycemia.
Choice B rationale
Obtaining blood glucose by heel stick is the correct step because diaphoresis, jitteriness, and lethargy in a newborn are classic signs of hypoglycemia. Timely detection and correction of blood glucose levels are critical.
Choice C rationale
Placing the newborn in a radiant warmer might help maintain body temperature but does not address the root cause of the symptoms, which is likely hypoglycemia.
Choice D rationale
Initiating phototherapy is used to treat jaundice (high bilirubin levels) and is not indicated for managing symptoms of hypoglycemia like diaphoresis, jitteriness, and lethargy.
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Correct Answer is C
Explanation
Choice A rationale
Dexamethasone is a corticosteroid and is not used for treating ectopic pregnancy.
Choice B rationale
Clomid (clomiphene citrate) is used to stimulate ovulation, not to treat ectopic pregnancy.
Choice C rationale
Methotrexate is a chemotherapeutic agent that effectively stops the growth of ectopic pregnancy cells, allowing the pregnancy tissue to be reabsorbed by the body.
Choice D rationale
Progesterone supports pregnancy and is not used to treat ectopic pregnancy.
Correct Answer is D
Explanation
Choice A rationale
Elevated WBC count is not typically associated with HELLP syndrome. HELLP syndrome involves hemolysis, elevated liver enzymes, and low platelet count.
Choice B rationale
Elevated platelet count is not a feature of HELLP syndrome. In fact, thrombocytopenia (low platelet count) is a hallmark of the condition.
Choice C rationale
Decreased BUN is not a characteristic of HELLP syndrome. The syndrome primarily affects liver function and platelets.
Choice D rationale
Elevated liver enzymes are a key diagnostic feature of HELLP syndrome, reflecting liver dysfunction and damage, which is part of the condition's pathology. .