A nurse is caring for a patient diagnosed with diabetic ketoacidosis.
Which of the following symptoms should the nurse expect?

Choice A rationale

Hypoglycemia, or low blood sugar, is a condition that can occur in newborns, especially those born to mothers with gestational diabetes. However, there is no information in the question indicating that the mother had gestational diabetes. Therefore, while hypoglycemia is a possible complication for newborns, it is not the most likely complication in this case based on the information provided.

Choice B rationale

Neonatal abstinence syndrome (NAS) is a group of problems that occur in a newborn who was exposed to addictive opiate drugs while in the mother’s womb. NAS can occur when a pregnant woman takes drugs such as heroin, codeine, oxycodone (Oxycontin), methadone, or buprenorphine. These and other substances pass through the placenta that connects the baby to its mother in the womb and can cause the baby to become dependent on the drug. In this case, the mother’s urine toxicology screen was positive for cocaine and marijuana, both of which are illicit drugs. This puts the newborn at risk for developing NAS2.

Choice C rationale

Respiratory distress syndrome (RDS) is a breathing disorder that affects newborns. RDS is more common in premature babies because their lungs aren’t fully developed. However, the newborn in the question was born at 38 weeks gestation, which is considered full term. Therefore, while RDS is a possible complication for newborns, it is not the most likely complication in this case based on the information provided.

Choice D rationale

Neonatal jaundice is a condition that can occur in newborns due to high levels of bilirubin, a yellow pigment produced during normal breakdown of red blood cells. In older babies and adults, the liver processes bilirubin, which then passes from the body through the stool and urine. However, a newborn’s still-developing liver may not be mature enough to remove this bilirubin. While neonatal jaundice is a common condition, there is no information in the question indicating that the newborn is at risk for developing this complication.

Choice A rationale

Assessing the amniotic fluid is important after rupture of membranes, but it is not the immediate priority. The nurse should first ensure the safety of the mother and baby.

Choice B rationale

Walking the patient to the bathroom is not the immediate priority. After rupture of membranes, the patient should be assisted back to bed to prevent cord prolapse.

Choice C rationale

Calling and informing the healthcare provider is important, but it is not the first action. The nurse should first assist the patient back to bed and initiate fetal monitoring.

Choice D rationale

Assisting the patient back to bed and initiating fetal monitoring is the correct action. After rupture of membranes, the priority is to assess the fetal heart rate for any signs of distress, such as bradycardia, which could indicate cord prolapse.