1. A nurse is caring for a newborn immediately following birth.

Exhibit 1

Medical History

Vacuum-assisted vaginal birth

Maternal history of positive group B streptococcus 8-hemolytic Mother received two doses of ampicillin IV bolus during labor

Exhibit 2

Vital Signs

Apgar:

Heart rate 96/min

Weak cry

Muscle tone: some flexion

Reflex: grimace

Color: acrocyanosis

Axillary temperature 36.9° C (98.5° F)

Exhibit 3

Medications

Erythromycin ophthalmic ointment once 1 to 2 hr after birth Hepatitis B vaccine 10 mcg/0.5 mL IM once within 24 hr after birth

Phytonadione 1 mg IM once 1 to 2 hr after birth

Exhibit 4

Laboratory Findings

WBC count 15,000mm (9,000 to 30,000/mm)

Hgb 19 g/dl (15 to 24 g/dL)

HCt 57% (44% to 70%)

Blood glucose 44 mg/dl (40 to 60 mg/dL)

The nurse is assessing the newborn 24 hr later. How should the nurse interpret the findings?

For each finding, click to specify whether the finding is unrelated to the diagnosis, an indication that the client's condition is improving, or indication that the client's condition is worsening

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. Abdominal distention:

Abdominal distention is not typically associated with hypoglycemia in newborns. It may be caused by other factors such as swallowed air during feeding or gastrointestinal issues.

B. Acrocyanosis:

Acrocyanosis, which is the blueness of the hands and feet, is a common finding in newborns and is not specific to hypoglycemia. It is often a result of the newborn's immature circulatory system.

C. Temperature instability:

Temperature instability, including hypothermia or hyperthermia, can occur in newborns for various reasons, but it is not specific to hypoglycemia.

D. Hypotonia:

Hypotonia, or decreased muscle tone, can be a sign of hypoglycemia in newborns. It may present as decreased activity, floppy movements, or poor feeding.

E.Jitteriness

Jitteriness, which is characterized by tremors or shaky movements, is a common manifestation of hypoglycemia in newborns. It is often observed when the newborn's blood glucose levels are low and can be a significant sign of hypoglycemia.