A nurse in a prenatal clinic is caring for a client who is suspected of having a hydatidiform mole. Which of the following findings should the nurse expect to observe in this client?

Choice A reason: Monitoring the newborn's blood pressure is not the most appropriate action, as it is not directly related to the signs of diaphoresis, jitteriness, and lethargy. These signs are more indicative of hypoglycemia, which is a low blood sugar level that can affect newborns, especially those who are premature, small for gestational age, or have diabetic mothers.

Choice B reason: Initiating phototherapy is not the most appropriate action, as it is used to treat hyperbilirubinemia, which is a high level of bilirubin in the blood that can cause jaundice, a yellowish discoloration of the skin and eyes. Hyperbilirubinemia does not cause diaphoresis, jitteriness, or lethargy.

Choice C reason: Obtaining blood glucose by heel stick is the most appropriate action, as it can confirm the diagnosis of hypoglycemia, which is the most likely cause of the signs of diaphoresis, jitteriness, and lethargy. The nurse should perform a heel stick using a sterile lancet and a glucose meter, and obtain a blood sample from the lateral aspect of the heel. The nurse should also provide warmth, stimulation, and feeding to the newborn, and report the blood glucose level to the provider.

Choice D reason: Placing the newborn in a radiant warmer is not the most appropriate action, as it can cause dehydration, fluid loss, and further hypoglycemia. The nurse should use a radiant warmer only if the newborn is hypothermic, which is a low body temperature that can also affect newborns. The nurse should monitor the newborn's temperature and skin color, and adjust the warmer accordingly.

Choice A reason: Using fingertips when calming the newborn is not recommended, as it can overstimulate the immature nervous system and cause stress. Instead, the nurse should use gentle, firm, and sustained touch, such as cupping the head and feet, or swaddling the newborn.

Choice B reason: Positioning the premature infant on their abdomen is contraindicated, as it can increase the risk of sudden infant death syndrome (SIDS). The nurse should position the newborn on their back or side, with a rolled blanket or towel to support the spine and prevent flattening of the head.

Choice C reason: Keeping the newborn in a well-lit nursery is not advisable, as it can interfere with the development of the circadian rhythm and sleep patterns. The nurse should provide a dark and quiet environment for the newborn, and expose them to natural light during the day.

Choice D reason: Clustering the newborn's care activities is beneficial, as it can reduce the number of disruptions and allow for longer periods of rest and growth. The nurse should plan and coordinate the care activities, such as feeding, bathing, changing, and assessing, to minimize the stress on the newborn.