A nurse is caring for a newborn who is formula-fed. The newborn takes 0.5 oz of formula at 0800, 1 oz at 1100, 0.5 oz at 1300, 0.5 oz at 1600, and 0.5 oz at 1830. How many mL of formula should the nurse record as the client's intake for the shift?

Choice A rationale:

Placing the newborn in a radiant warmer may provide warmth, but it does not address the observed signs of respiratory distress, jitteriness, and lethargy. These signs indicate potential respiratory and neurological issues, which need to be assessed and managed promptly.

Choice B rationale:

Initiating phototherapy is not appropriate for the observed signs of respiratory distress, jitteriness, and lethargy. Phototherapy is used to treat neonatal jaundice caused by elevated bilirubin levels, which is not evident from the given information.

Choice C rationale:

The nurse should obtain blood glucose by heel stick to assess the newborn's blood sugar levels. The signs of jitteriness and lethargy may be indicative of hypoglycemia (low blood sugar), which is common in newborns. Early detection and intervention are crucial to prevent complications and ensure the baby's well-being.

Choice D rationale:

Measuring the newborn's blood pressure is not the priority at this moment. The observed signs suggest respiratory distress and potential hypoglycemia, which need immediate attention. Blood pressure assessment may be important later on, but it is not the first action the nurse should take based on the given information.

A. A blood glucose fingerstick of 40 mg/dL for an infant who is 1-hr old: A blood glucose level of 40 mg/dL is borderline low but expected in the immediate postnatal period, especially if the infant is asymptomatic. Feeding the infant is the first step to address this, and monitoring is usually sufficient unless symptoms of hypoglycemia develop.

B. A hematocrit of 60% in an infant who is 8-hr old: This value is at the upper end of normal for a newborn and may suggest mild polycythemia. However, it does not require urgent notification unless accompanied by symptoms such as respiratory distress or poor perfusion

C. Jaundice in an infant who is 4-hr old: Early-onset jaundice (within the first 24 hours) is not normal and suggests a potentially dangerous underlying condition, such as hemolytic disease of the newborn or infection. Immediate reporting and further evaluation, including bilirubin levels and possible treatment with phototherapy, are essential.

D. Acrocyanosis in an infant who is 2-hr old: Acrocyanosis (bluish discoloration of the hands and feet) is a common and benign finding in the first 24 to 48 hours after birth due to immature circulation. It does not require notification or intervention.