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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

Placenta formation begins shortly after implantation, but it continues to develop throughout the first trimester and into the early second trimester, making it less precise to attribute the

first 8 weeks solely to this process.

Choice B rationale

Fertilization occurs within the first week after ovulation, marking the beginning of pregnancy, but it is a singular event that happens prior to the developmental processes vulnerable to teratogens.

Choice C rationale

Organogenesis is the critical period during which the major organs and structures of the fetus form, typically occurring between the third and eighth weeks of gestation. This is the

time when the fetus is most susceptible to the effects of teratogens, which can cause congenital anomalies.

Choice D rationale

Implantation occurs approximately 6-10 days after fertilization, embedding the blastocyst into the uterine lining. While crucial, it is not the primary period when teratogenic effects are

most significant, as this happens during organogenesis.

Correct Answer is A

Explanation

Choice A rationale

Betamethasone is a corticosteroid that accelerates fetal lung maturity by increasing the production of surfactant, which reduces respiratory distress syndrome in preterm infants.

Choice B rationale

While betamethasone can cause transient increases in fetal heart rate, its primary purpose is not to increase fetal heart rate. Its role is in enhancing lung maturity.

Choice C rationale

Betamethasone does not directly increase amniotic fluid levels. Its main function is in the maturation of fetal lungs.

Choice D rationale

Betamethasone is not used to stop preterm labor contractions. It is used to accelerate fetal lung development in preterm labor cases.

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