A nurse is caring for a newborn who exhibits signs of diaphoresis, jitteriness, and lethargy.Which of the following actions should the nurse take?
Place the newborn in a radiant warmer.
Monitor the newborn's blood pressure.
Initiate phototherapy.
Obtain blood glucose by heel stick.
The Correct Answer is D
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A rationale
Platelets at 140,000 mg are within the normal range and are not typically indicative of postpartum complications like a thrombus.
Choice B rationale
Hemoglobin at 7 mg/dl indicates anemia but is not directly related to the symptoms of pain and tenderness in the calf.
Choice C rationale
A WBC count of 15,000 could indicate an infection or inflammatory process but is not specific to deep vein thrombosis (DVT).
Choice D rationale
Fibrinogen at 600 mg/dl is elevated and can be a marker for increased coagulation activity, which is associated with an increased risk of thrombosis. .
Correct Answer is C
Explanation
Choice A rationale
Focusing primarily on her own needs is characteristic of the taking-in phase, where the mother is more self-focused and recovering from the birth process.
Choice B rationale
Being very excited and talkative about the birth experience is also a trait of the taking-in phase, not the taking-hold phase.
Choice C rationale
Interest in learning about infant care indicates the taking-hold phase, where the mother becomes more focused on the baby's needs and her new role as a caregiver.
Choice D rationale
Relying on nursing staff for assistance is common in the taking-in phase, where the mother depends more on others for care.
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