A nurse is collecting data from a newborn who is 4 hours old.
Which of the following findings should the nurse report to the provider?

Choice A rationale

Hypoglycemia in a newborn, defined as a plasma glucose level typically below 40 to 50 mg/dL, starves the central nervous system of its primary energy source, glucose. This lack of fuel in the brain cells often presents with neurological symptoms. Jitteriness (or tremors) is a classic and early neurogenic sign of this metabolic disturbance, resulting from sympathetic nervous system activation.

Choice B rationale

Hypoglycemia typically results in an attempt by the body to conserve energy and may lead to poor peripheral perfusion and decreased metabolic rate, which often manifests as hypothermia (decreased temperature). Increased temperature (hyperthermia) is not a sign of hypoglycemia; instead, it is often associated with infection or environmental overheating.

Choice C rationale

Hypoglycemia causes central nervous system instability and depression, which generally results in a decrease in a newborn's reflexes and muscle tone (hypotonia), or can lead to lethargy and poor feeding. Therefore, brisk reflexes (hyperreflexia) are not a characteristic finding and would suggest other neurological or metabolic conditions.

Choice D rationale

The Moro reflex (or startle reflex) is a complex, primitive reflex that is present and intact in healthy newborns. While severe hypoglycemia can lead to generalized central nervous system depression, which could eventually suppress all reflexes, an absence of a Moro reflex is a more specific sign of a severe neurological injury or a congenital neurological disorder, not a typical early sign of hypoglycemia.

Choice A rationale

The Lamaze technique for childbirth preparation utilizes conditioned responses to cope with labor pain, which includes specific signals from the coach, a learned response (like a specific breathing pattern), and relaxation techniques. This approach aims to reduce the perception of pain by focusing attention and promoting muscular release through psychoprophylaxis.

Choice B rationale

Using tennis balls on the sacral area to lean against is a non-pharmacological pain relief technique, but it's a form of counter-pressure applied to the lower back, often effective for back labor, not an instruction specific to the technique of acupressure. Counter-pressure helps to relieve the referred pain caused by the fetus's occiput pressing against the sacrum.

Choice C rationale

Using light, rhythmic strokes on the abdomen, known as effleurage, along with rhythmic breathing, is a touch/massage technique often taught in childbirth classes. It provides a distracting sensory input and promotes relaxation, but it is not the specific method for applying acupressure, which involves sustained pressure on specific body points.

Choice D rationale

Immersing oneself in a tub of warm water is hydrotherapy, a non-pharmacological technique used to relax muscles and reduce pain perception during labor. The warmth promotes vasodilation and aids in relaxation, providing a soothing environment. This method is distinct from the localized pressure application of acupressure.