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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 C

Explanation

Choice A rationale

Decreased deep tendon reflexes are not typically associated with preeclampsia. In fact, hyperreflexia or increased deep tendon reflexes might be observed due to central nervous

system irritability in preeclampsia.

Choice B rationale

Uterine contractions are related to labor and not a specific indicator of preeclampsia. While they might occur simultaneously, they are not diagnostic of preeclampsia.

Choice C rationale

Proteinuria, the presence of excess protein in the urine, is a key diagnostic criterion for preeclampsia. It indicates kidney involvement and is used along with elevated blood pressure to diagnose this condition.

Choice D rationale

Increased blood glucose levels are associated with gestational diabetes rather than preeclampsia. Elevated blood pressure and proteinuria are the hallmarks of preeclampsia.

Correct Answer is C

Explanation

Choice A rationale

The placenta does not provide thermoregulation; that function is managed by maternal thermoregulation and the amniotic fluid which insulates the fetus.

Choice B rationale

Amniotic fluid cushions the fetus from maternal movements, not the placenta. The placenta's role is more focused on nutrient and waste exchange.

Choice C rationale

The placenta facilitates metabolic functions and gas exchange, supplying oxygen and nutrients to the fetus while removing carbon dioxide and waste products, ensuring fetal development.

Choice D rationale

The placenta doesn't provide a sterile environment. This is accomplished by the amniotic sac and amniotic fluid. The placenta connects the fetus to maternal blood supply, ensuring necessary exchanges for fetal growth.

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