A nurse is caring for a term newborn male client who is 72 hours old in the neonatal intensive care unit. The newborn was born after a precipitous vaginal birth at 39 weeks of gestation. The mother has a history of opioid use during pregnancy.

Exhibits

The nurse is assessing the newborn 24 hours later. For each finding, specify whether the finding is unrelated to the diagnosis, a sign of potential improvement, or a sign of potential worsening condition.

• Neonatal hypoglycemia: The newborn’s blood glucose level is 30 mg/dL, which is below the normal range. This, along with the jitteriness, weak cry, and mottled skin with acrocyanosis, suggests the newborn is most likely experiencing neonatal hypoglycemia.
• Actions to take: The nurse should administer a 10% dextrose IV bolus as prescribed by the provider to increase the newborn’s blood glucose levels. The nurse should also monitor the newborn’s blood glucose levels every 30 minutes to ensure they are increasing towards the normal range.
• Parameters to monitor: The nurse should monitor the newborn’s blood glucose levels to ensure they are increasing towards the normal range. The nurse should also monitor the newborn’s heart rate, as tachycardia can be a sign of hypoglycemia. If the newborn’s condition does not improve or worsens, the nurse should notify the healthcare provider immediately.

The correct answer is choiced. Inform the client about the possible need for reduction of multiple fetuses.

Choice A rationale:

Instructing the client not to use donor oocytes is not accurate.Donor oocytes can be a viable option for clients with certain infertility issues, such as ovarian insufficiency or genetic concerns.

Choice B rationale:

Informing the client that sperm will be introduced to the uterus during ovulation is incorrect.In vitro fertilization involves fertilizing the eggs outside the body in a laboratory setting, not directly introducing sperm into the uterus.

Choice C rationale:

Instructing the client to avoid freezing embryos for possible use in the future is not appropriate.Freezing embryos is a common practice in IVF to allow for future attempts if the initial cycle is unsuccessful.

Choice D rationale:

Informing the client about the possible need for reduction of multiple fetuses is correct.IVF can result in multiple pregnancies, and in some cases, fetal reduction may be recommended to ensure the health and safety of the mother and remaining fetuses.