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","D","F"]
Explanation
Choice A rationale:
Supplementing with formula is not necessary based on the given information. The baby is voiding and passing stools adequately, indicating proper feeding. Instead, feeding on demand and ensuring frequent breastfeeding will help address any concerns about the baby's weight.
Choice B rationale:
Feeding 8 to 12 times per day and on demand is recommended to ensure adequate milk supply and proper growth and development of the newborn. Frequent feeding helps to establish and maintain milk production.
Choice C rationale:
Using plastic-lined breast pads is not recommended as they can trap moisture and create an environment that promotes nipple irritation and infection. It is better to use breathable, non-plastic-lined breast pads.
Choice D rationale:
It is correct that a newborn's stools should transition from the dark greenish color meconium to a yellow color within a few days as the baby begins digesting breast milk.
Choice E rationale:
Drinking more whole milk does not directly increase a mother's milk supply. Milk supply is primarily regulated by the frequency and efficiency of breastfeeding or pumping.
Choice F rationale:
Expecting the breasts to feel full, warm, and slightly tender when the milk comes in is accurate. This usually occurs around the third or fourth day postpartum and indicates that the milk production process is underway.
Correct Answer is C
Explanation
Choice A rationale
G4T1 P1 A1 L2 implies the client has been pregnant 4 times, with 1 term birth, 1 preterm birth, 1 abortion, and 2 living children. This does not include the correct number of
pregnancies or abortions for this client.
Choice B rationale
G5T2 P0 A2 L2 indicates 5 pregnancies, 2 term births, no preterm births, 2 abortions, and 2 living children. This does not correctly account for the preterm birth and abortion history
provided.
Choice C rationale
G5T1 P1 A2 L2 is the correct answer, as it denotes 5 pregnancies (including the current one), 1 term birth, 1 preterm birth, 2 abortions, and 2 living children, aligning with the client's
history.
Choice D rationale
G5T1 P1 A1 L3 indicates 5 pregnancies, 1 term birth, 1 preterm birth, 1 abortion, and 3 living children. The client has only 2 living children, so this is incorrect.