A nurse is caring for a client who is in labor.The nurse notes that the umbilical cord is protruding from the client’s vagina. Which of the following actions should the nurse take first?

Choice A rationale

Applying hydrating lotion to the newborn’s skin prior to treatment is not recommended. The goal of phototherapy is to expose the newborn’s skin to light, and applying lotion could potentially interfere with the effectiveness of the treatment.
Choice B rationale
Providing the newborn with 15 mL glucose water after each feeding is not a standard part of phototherapy treatment. The newborn should continue to receive regular feedings, but additional glucose water is not typically necessary.
Choice C rationale
Turning the newborn every 4 hours is not sufficient during phototherapy. The newborn should be repositioned frequently, ideally every 2-3 hours, to expose all areas of the skin to the light.
Choice D rationale
It is important to protect the newborn’s eyes during phototherapy to prevent damage from the light. Therefore, the newborn’s eyes should be covered with special patches whenever the lights are on.

• Neonatal hypoglycemia: The newborn’s blood glucose level is 30 mg/dL, which is below the normal range. This, along with the jitteriness, weak cry, and mottled skin with acrocyanosis, suggests the newborn is most likely experiencing neonatal hypoglycemia.
• Actions to take: The nurse should administer a 10% dextrose IV bolus as prescribed by the provider to increase the newborn’s blood glucose levels. The nurse should also monitor the newborn’s blood glucose levels every 30 minutes to ensure they are increasing towards the normal range.
• Parameters to monitor: The nurse should monitor the newborn’s blood glucose levels to ensure they are increasing towards the normal range. The nurse should also monitor the newborn’s heart rate, as tachycardia can be a sign of hypoglycemia. If the newborn’s condition does not improve or worsens, the nurse should notify the healthcare provider immediately.