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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 B

Explanation

Choice A rationale

Prolapsed cord involves the umbilical cord descending into the birth canal ahead of the fetus, which is a critical emergency but presents differently, typically with changes in fetal

heart rate and the cord being palpable or visible.

Choice B rationale

Abruptio placentae is characterized by the premature separation of the placenta from the uterine wall, which can cause severe abdominal pain, vaginal bleeding, and is a medical

emergency requiring immediate intervention to prevent maternal and fetal complications.

Choice C rationale

Placenta previa involves the placenta partially or completely covering the cervical opening, which can cause painless vaginal bleeding but does not typically present with severe

abdominal pain.

Choice D rationale

Incompetent cervix is associated with painless cervical dilation and potential preterm labor but not typically with severe abdominal pain and acute vaginal bleeding as seen with

abruptio placentae

Correct Answer is D

Explanation

Choice A rationale

A family history of breast cancer, particularly in a close relative like a sister, is a significant risk factor for breast cancer.

Choice B rationale

Exposure to radiation, particularly in the chest area, increases the risk of developing breast cancer.

Choice C rationale

Current use of oral contraceptives can slightly increase the risk of breast cancer, though the risk diminishes after stopping the pills.

Choice D rationale

Age less than 25 years is not a risk factor for breast cancer; risk increases with age.

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