A nurse is assessing a newborn who is 2 hr old. Which of the following findings is an indication of hypoglycemia? (Select all that apply.)

A. Assess for edema:

Assessing for edema is important in monitoring the client's condition as edema can be a sign of worsening preeclampsia. However, it is not an action that requires immediate intervention in the first hour postpartum.

B. Administer an IV bolus of lactated Ringer's:

Administering an IV bolus of lactated Ringer's is not typically indicated for a client with preeclampsia without severe features unless there is evidence of dehydration or hypovolemia. Intravenous fluids may be administered judiciously based on the client's clinical status and fluid balance.

C. Restrict daily oral fluid intake:

Restricting daily oral fluid intake is not recommended for a client in the immediate postpartum period, especially without severe features of preeclampsia. Adequate hydration is important for postpartum recovery and breastfeeding.

D. Obtain a prescription for misoprostol:

Misoprostol is a medication used for various purposes in obstetrics, including the prevention and treatment of postpartum hemorrhage. However, it is not specifically indicated for the management of preeclampsia without severe features. The priority in this situation is close monitoring and supportive care rather than medication administration.

A. "I should avoid breastfeeding for 2 weeks following the immunization."

This statement is incorrect. There is no need to avoid breastfeeding after receiving the rubella vaccine. Breastfeeding is safe and not contraindicated following immunization with the rubella vaccine. Breastfeeding can continue as usual without interruption.

B. "I should avoid becoming pregnant for at least 1 month following the immunization."

This statement is correct. Following administration of the rubella vaccine, it is recommended to avoid becoming pregnant for at least 1 month. This precaution is due to theoretical concerns about the vaccine potentially affecting the developing fetus if a woman were to become pregnant shortly after vaccination. Rubella infection during pregnancy can cause serious birth defects, so it's important to take precautions to avoid potential harm to the fetus.

C. "I will report joint pain that develops after the immunization to my provider immediately."

While joint pain can be a rare side effect of the rubella vaccine, it is not typically necessary to report it immediately unless it is severe or persistent. Mild joint pain is a common and expected side effect of some vaccines, including the rubella vaccine, and typically resolves on its own without intervention. However, if joint pain is severe or persistent, it may be appropriate to report it to a healthcare provider for further evaluation and management.