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A nurse is caring for a newborn and observes signs of diaphoresis, jitteriness, and lethargy.
Which of the following actions should the nurse take?

A.

Monitor the newborn's blood pressure.

B.

Obtain blood glucose by heel stick.

C.

Place the newborn in a radiant warmer.

D.

Initiate phototherapy.

Answer and Explanation

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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View Related questions

Correct Answer is ["A","B","C"]

Explanation

Choice A: Give betamethasone 12 mg IM now and repeat in 24 hr.

Rationale: Betamethasone is administered to accelerate fetal lung maturity in cases of preterm labor. Given the client's gestational age of 31 weeks, this intervention is appropriate to help reduce the risk of respiratory distress syndrome in the newborn.

Choice B: Begin loading dose of magnesium sulfate 9 g over 30 min.

Rationale: Magnesium sulfate is used for neuroprotection of the fetus in preterm labor to reduce the risk of cerebral palsy. The loading dose is typically given to achieve therapeutic levels quickly.

Choice C: Position the client in a lateral position.

Rationale: Positioning the client in a lateral position helps improve uteroplacental blood flow and can reduce the intensity of contractions, which is beneficial in managing preterm labor.

Correct Answer is B

Explanation

Choice A rationale

Precipitous labor is a rapid labor that typically lasts less than 3 hours. While it can result in trauma and complications, it does not inherently increase the risk for an operative delivery,

which is more often related to other factors like fetal distress or failure to progress.

Choice B rationale

Postpartum hemorrhage (PPH) is a significant concern with precipitous labor due to the rapid and forceful contractions that can cause uterine atony, leading to increased bleeding

after birth.

Choice C rationale

In a precipitous labor, the rapid delivery can cause vaginal lacerations, not a decreased risk. The swift passage of the baby through the birth canal increases the risk of tears and

trauma.

Choice D rationale

Neonatal sepsis is related to infections acquired during delivery but is not specifically linked to the speed of labor. The primary concern in precipitous labor is maternal trauma and

hemorrhage, not infection.

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