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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 D

Explanation

Choice A rationale

Administering the rubella vaccine during pregnancy, including the third trimester, is contraindicated due to the risk of live vaccine transmission to the fetus. It is not recommended at any stage of pregnancy.

Choice B rationale

Advising the client to get the vaccine during her next pregnancy attempt is partly correct but lacks the immediacy needed to ensure she is immune before the next pregnancy. The vaccine should be given postpartum.

Choice C rationale

Administering the vaccine immediately during pregnancy is contraindicated due to potential risks to the fetus. Rubella vaccines contain live virus, which can cause fetal harm if given during pregnancy.

Choice D rationale

It is safest to administer the rubella vaccine postpartum, prior to hospital discharge, to ensure the client has immunity before any future pregnancies. This timing prevents any risk to the current fetus and ensures future fetal protection. .

Correct Answer is D

Explanation

Choice A rationale

A rapid pulse is not typically associated with magnesium toxicity. Magnesium toxicity more commonly affects the nervous and muscular systems.

Choice B rationale

Tingling in toes can be a sign of early magnesium sulfate effects but not necessarily toxicity. It may indicate that the medication is starting to affect the nervous system.

Choice C rationale

Cool skin temperature is not a common sign of magnesium toxicity. Symptoms of magnesium toxicity are more related to neuromuscular and respiratory function.

Choice D rationale

Absent deep tendon reflexes are a key indicator of magnesium toxicity. This finding suggests that magnesium levels are high enough to depress neuromuscular function, requiring immediate medical intervention. .

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