A nurse is caring for a client who is Rh negative.
Which of the following findings would cause the nurse to administer Rh immunoglobulin?

Choice A rationale

Placing the newborn in a radiant warmer is appropriate for managing hypothermia but does not directly address the signs of diaphoresis, jitteriness, and lethargy, which are indicative of hypoglycemia.

Choice B rationale

Monitoring the newborn's blood pressure is not the primary action needed for signs of hypoglycemia. The immediate need is to check blood glucose levels and address any hypoglycemia.

Choice C rationale

Initiating phototherapy is a treatment for hyperbilirubinemia (jaundice) and is not related to the signs of diaphoresis, jitteriness, and lethargy seen in hypoglycemia.

Choice D rationale

Obtaining blood glucose by heel stick is the correct action as the signs of diaphoresis, jitteriness, and lethargy are indicative of hypoglycemia. Checking blood glucose levels will help in diagnosing and managing the condition.

Choice A rationale

Stools are a normal occurrence in newborns and are not typically associated with significant complications. The frequency and consistency can vary, but abnormal stools would not explain the given vital signs.

Choice B rationale

Temperature control is vital in newborns, but the given temperature is slightly low and alone does not indicate a specific complication without additional context such as infection or environment.

Choice C rationale

Feeding difficulties can occur in newborns, but they would typically present with symptoms related to weight and growth rather than the specific vital signs provided.

Choice D rationale

Extremities’ conditions, such as cyanosis or poor circulation, could indicate complications, but the given vital signs are not directly indicative of extremity problems.

Choice E rationale

Hypoglycemia in newborns can present with signs like jitteriness or lethargy, but it does not directly correlate with the provided vital signs without additional glucose measurements.

Choice F rationale

Neonatal Abstinence Syndrome (NAS) includes symptoms such as high heart rate, respiratory rate, and temperature instability, which align with the newborn's vital signs.