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
Explanation
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.
Correct Answer is D
Explanation
Choice A rationale
Severe nausea and vomiting, known as hyperemesis gravidarum, are more commonly associated with high levels of human chorionic gonadotropin (hCG) and are not specific to
ectopic pregnancy.
Choice B rationale
While vaginal bleeding can occur in an ectopic pregnancy, it is usually not a large amount. The bleeding in ectopic pregnancy tends to be light and irregular.
Choice C rationale
Uterine enlargement greater than expected for gestational age is typically associated with conditions like molar pregnancy, not ectopic pregnancy, as the pregnancy is located outside
the uterus.
Choice D rationale
Unilateral, cramp-like abdominal pain is a classic symptom of ectopic pregnancy as the fertilized egg implants outside the uterus, most commonly in a fallopian tube, causing
localized pain.