A newborn develops hyperbilirubinemia when 24 hours old and is prescribed phototherapy.
Which measure is an important part of this newborn’s care plan?

Answer and explanation..

The correct answer is choice C. Jitteriness.Jitteriness is a sign of low blood sugar (hypoglycemia) which is common in infants of diabetic mothers (IDM) because they have high levels of insulin in their blood that lower their glucose levels after birth.Hypoglycemia can also cause other symptoms such as seizures, lethargy, poor feeding, sweating, trembling, and pale complexion.

Choice A is wrong because abdominal distention is not a typical symptom of IDM.

It can be caused by other conditions such as intestinal obstruction or infection.

Choice B is wrong because high-pitched cry is not a specific symptom of IDM.

It can be caused by many factors such as pain, hunger, or neurological problems.

Choice D is wrong because excessive drooling is not a common symptom of IDM.

It can be a sign of oral problems such as teething or infection.

Normal ranges for blood glucose in newborns are 40 to 150 mg/dL (2.2 to 8.3 mmol/L).

IDM should be monitored closely for hypoglycemia and treated promptly with glucose if needed.

The correct answer is choice A. Maintaining the infants’ airways is the nurse’s priority when caring for a set of twins delivered by cesarean delivery.This is because twins are more likely to be born early and need special care after birth than single babies.They may have breathing difficulties or low oxygen levels and require oxygen therapy or ventilation.

The nurse should assess the infants’ respiratory status and intervene as needed.

Choice B is wrong because keeping the infants in a warm, draft-free environment is important but not as urgent as ensuring their airways are clear and they are breathing well.Premature twins may have trouble regulating their body temperature and need to be kept warm, but this can be done after their airways are secured.

Choice C is wrong because placing identification bands on the infants is a standard procedure but not a priority.

The nurse should make sure the infants are correctly identified and matched with their mother, but this can be done after their vital signs are stable.

Choice D is wrong because monitoring the infants’ vital signs is also important but not as urgent as maintaining their airways.

The nurse should check the infants’ heart rate, blood pressure, temperature and blood sugar levels regularly, but this can be done after their respiratory status is assessed and managed.

Normal ranges for vital signs in newborns are:

• Heart rate: 100 to 160 beats per minute

• Blood pressure: 50 to 75 mm Hg systolic and 30 to 45 mm Hg diastolic

• Temperature: 36.5 to 37.5°C (97.7 to 99.5°F)

• Blood sugar: 40 to 80 mg/dL