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","E","F"]
Explanation
Choice A rationale:
The statement suggests supplementing with formula due to the baby’s weight loss. However, a 5% weight loss in the first few days is normal for breastfed infants, and formula
supplementation is not necessary unless recommended by a healthcare provider. Early breastfeeding should be encouraged to increase milk supply and support newborn weight gain.
Choice B rationale:
This statement correctly indicates that newborns should feed 8 to 12 times per day and on demand to ensure adequate nutrition and promote milk production. Frequent breastfeeding
helps establish and maintain milk supply.
Choice C rationale:
Using plastic-lined breast pads can retain moisture and increase the risk of infection or irritation. Sore nipples can be managed with lanolin creams, air-drying, and proper latching
techniques during breastfeeding.
Choice D rationale:
Drinking more whole milk is a common misconception and does not directly increase a mother's milk supply. Milk production is influenced by frequent breastfeeding, proper hydration,
and balanced nutrition, not by specific types of foods or drinks.
Choice E rationale:
Newborn stools transition from dark greenish meconium to yellow, seedy stools within the first few days of life as breastfeeding becomes established. This indicates effective feeding
and milk intake.
Choice F rationale:
It is normal for a breastfeeding mother’s breasts to feel full, warm, and slightly tender as her milk comes in. This indicates that the milk supply is increasing and the body is responding
to the newborn’s feeding needs.
Correct Answer is C
Explanation
Choice A rationale
A maternal blood pressure of 128/88 mm Hg is within normal limits for a pregnant woman. Regular monitoring is necessary, but no immediate follow-up is required unless symptoms
of preeclampsia appear.
Choice B rationale
A fetal heart rate baseline of 115 bpm is within the normal range (110-160 bpm). This does not require immediate follow-up and is a reassuring sign of fetal well-being.
Choice C rationale
A maternal heart rate of 128 bpm is elevated (tachycardia) and may indicate distress, infection, dehydration, or other underlying conditions. This requires immediate follow-up to identify and address the cause.
Choice D rationale
A maternal respiratory rate of 18 breaths per minute is within the normal range (12-20 breaths per minute) and does not require immediate follow-up.