A nurse is assisting with the care of a client who is beginning the third stage of labor.
Which of the following actions should the nurse take first?

Choice A rationale: Rechecking the newborn’s temperature is essential because the earlier reading of 36.3°C (97.3°F) was below the normal range of 36.5–37.5°C. Hypothermia in neonates can exacerbate hypoglycemia by increasing metabolic demands. Monitoring temperature ensures thermoregulation is maintained, which is critical for stabilizing glucose levels and preventing further complications in the early neonatal period.

Choice B rationale: Scheduling a lactation consult is appropriate due to the newborn’s initial difficulty latching. Effective breastfeeding is crucial for maintaining adequate glucose levels, especially in a macrosomic infant at risk for hypoglycemia. A lactation consultant can assess latch technique, feeding cues, and milk transfer to ensure the newborn receives sufficient nutrition and to support maternal confidence and bonding.

Choice C rationale: Rechecking the glucose level is warranted because the newborn previously had a hypoglycemic reading of 35 mg/dL, followed by a borderline normal value of 50 mg/dL. Continued monitoring is necessary to ensure glucose stability, especially in a macrosomic infant who may have persistent hyperinsulinemia. Serial glucose checks help detect recurrent hypoglycemia and guide further interventions.

Choice D rationale: Reinforcing hourly breastfeeding is not evidence-based and may lead to feeding fatigue for both the newborn and parent. Newborns typically feed every 2 to 3 hours. Overfeeding attempts can cause stress and interfere with effective feeding. Instead, feeding should be based on hunger cues and guided by lactation support to ensure quality rather than quantity of feeds.

Choice E rationale: Ensuring the newborn is tightly swaddled helps maintain body temperature and provides a calming, secure environment. Swaddling reduces energy expenditure, which is important in preventing further glucose depletion. It also helps soothe jitteriness and supports neuromuscular tone, both of which are affected in hypoglycemic states. Proper swaddling is a key nonpharmacologic intervention in neonatal care.

Choice F rationale: Encouraging skin-to-skin contact promotes thermoregulation, stabilizes glucose levels, and enhances breastfeeding success. This practice stimulates oxytocin release, improves maternal-infant bonding, and reduces stress responses in the newborn. For infants at risk of hypoglycemia, skin-to-skin contact is a first-line supportive measure that complements nutritional and metabolic interventions.

Choice G rationale: Maintaining an intravenous catheter for glucose administration is not indicated at this time. The newborn’s glucose level improved to 50 mg/dL after feeding, and the infant is now stable, alert, and feeding. IV glucose is reserved for symptomatic hypoglycemia unresponsive to feeding or when glucose levels remain critically low. In this case, noninvasive measures are sufficient.

Choice A rationale

The newborn's fingers curling around the nurse's finger when placed in the palm describes the grasping reflex, also known as the palmar grasp. This is an expected neurological finding in a full-term newborn, indicating intact primitive reflexes and proper neurological development. This reflex typically persists until about 5-6 months of age.

Choice B rationale

The newborn closing their eyes and keeping them closed when tapped on the forehead is not a typical expected reflex. This describes the glabellar reflex, which involves blinking in response to tapping between the eyebrows. However, sustained eye closure without blinking is not a characteristic normal finding, suggesting potential neurological variation.

Choice C rationale

The newborn turning their head away from the stimulus when their cheek is touched is an unexpected finding. The rooting reflex, a normal primitive reflex, involves the newborn turning their head *towards* the stimulus and opening their mouth when the cheek or corner of the mouth is touched. Turning away would suggest an absent or atypical reflex response.

Choice D rationale

The newborn's legs flexing at the knees and hips when pressure is applied to the soles of the newborn's feet is known as the stepping or walking reflex. This reflex involves coordinated leg movements resembling walking. However, the description here is vague; the plantar grasp reflex involves toe curling, and strong, isolated flexion is not typically the sole response.