A nurse is performing a physical examination of a client who is 1 day postpartum. Which of the following findings requires immediate intervention?

A) Educate parents on blood glucose monitoring:

Blood glucose monitoring is not directly related to the care of a newborn with phenylketonuria (PKU). PKU is a metabolic disorder that affects the body's ability to process phenylalanine, an amino acid found in protein. Therefore, educating parents on blood glucose monitoring is not relevant to the management of PKU.

B) Obtain a blood sample for blood type:

Obtaining a blood sample for blood type is a routine procedure performed shortly after birth to determine the newborn's blood type and Rh factor. While this is an important aspect of newborn care, it is not specific to the management of PKU.

C) Administer thyroid hormone replacement:

Administering thyroid hormone replacement is not indicated for a newborn with PKU. PKU is a metabolic disorder caused by a deficiency of the enzyme phenylalanine hydroxylase, which leads to the accumulation of phenylalanine in the body. Thyroid hormone replacement is used to treat hypothyroidism, a condition involving an underactive thyroid gland, and is not related to PKU management.

D) Initiate a controlled low-protein diet:

Initiating a controlled low-protein diet is a crucial aspect of managing PKU. Since PKU is characterized by the inability to metabolize phenylalanine properly, dietary management aims to limit phenylalanine intake by implementing a low-protein diet. This diet helps prevent the accumulation of phenylalanine in the body, reducing the risk of neurological damage and other complications associated with PKU. Therefore, including this action in the plan of care is essential for effectively managing PKU in the newborn.

B) Vitamin K injection:

This is correct. Administration of vitamin K injection is a routine practice in newborn care immediately following birth. Newborns have low levels of vitamin K, which is necessary for blood clotting. The injection helps prevent vitamin K deficiency bleeding (VKDB), a serious condition that can occur in newborns.

D) Antibiotic ointment to both eyes:

This is correct. Administration of antibiotic ointment to both eyes is standard practice to prevent neonatal conjunctivitis, which can be caused by organisms such as Neisseria gonorrhoeae or Chlamydia trachomatis acquired during passage through the birth canal. The ointment helps prevent eye infections and is typically administered shortly after birth.

A) Tdap:

Tdap (tetanus, diphtheria, acellular pertussis) vaccine is not routinely administered immediately following birth. It is typically given to pregnant individuals during the third trimester to provide passive immunity to the newborn and protect against pertussis (whooping cough).

C) Haemophilus influenza type b immunization (Hib):

Hib immunization is not typically administered immediately following birth. It is a childhood vaccine that protects against Haemophilus influenzae type b, a bacterial infection that can cause serious illnesses such as meningitis and pneumonia. The vaccine is usually given in a series of doses starting at 2 months of age.

E) Lidocaine gel to the umbilical stump:

Application of lidocaine gel to the umbilical stump is not a standard practice in newborn care immediately following birth. The umbilical cord stump typically dries and separates naturally over the first few weeks of life, and routine application of lidocaine gel is not necessary for its care.