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 B
Explanation
Choice A rationale
The supine position is not recommended for breastfeeding because it can lead to issues with latching and milk flow, making it uncomfortable and potentially unsafe.
Choice B rationale
The cradle position is a common and effective breastfeeding position where the baby's head rests in the crook of the mother's arm, allowing for close contact and support.
Choice C rationale
Upright with chin support is not a standard breastfeeding position and may not provide the necessary support or alignment for effective breastfeeding.
Choice D rationale
Over-the-shoulder is also not a recommended breastfeeding position as it is impractical and does not facilitate proper latching or feeding.
Correct Answer is B
Explanation
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.