A charge nurse is speaking with the partner of a client. The partner states that the client is not receiving adequate care. Which of the following actions should the charge nurse take first to resolve the situation?

Irritability.

The rationale for each choice is as follows:

• A. Irritability: Correct. Irritability is one of the signs of hypoglycemia, which occurs when blood glucose levels fall below 70 mg/dL (3.9 mmol/L). Other signs include shakiness, sweating, hunger, headache, confusion, and blurred vision.
• B. Increased urination: Incorrect. Increased urination is one of the signs of hyperglycemia, which occurs when blood glucose levels rise above 180 mg/dL (10 mmol/L). Other signs include thirst, dry mouth, fatigue, nausea, and fruity breath odor.
• C. Vomiting: Incorrect. Vomiting is not a specific sign of hypoglycemia or hyperglycemia, but it can occur as a complication of either condition if left untreated or poorly managed.
• D.Facial flushing: Incorrect. Facial flushing is not a sign of hypoglycemia or hyperglycemia, but it can occur as a side effect of some medications used to treat diabetes, such as niacin or rosiglitazone.

• A is incorrect because assessing the apical pulse while the newborn is crying can result in an inaccurate measurement due to increased heart rate and respiratory rate.
• B is incorrect because palpating the radial pulse for 30 seconds is not appropriate for a newborn as it can be difficult to locate and count accurately.
• C is incorrect because listening to the apical pulse while palpating the radial pulse is not necessary for a newborn and can be confusing and time-consuming.
• D is correct because auscultating the apical pulse at least 1 min is the best way to assess a newborn's heart rate as it provides an accurate and reliable measurement.