A nurse is providing teaching about foot care to a client who has diabetes mellitus. Which of the following instructions should the nurse include? (Select all that apply)

Rationale for correct choices

• Hypoglycemia: The newborn’s birth weight is 4200 g (9 lb 4 oz), indicating macrosomia. Infants of this size, especially after cesarean delivery, are at increased risk for hypoglycemia due to potential neonatal hyperinsulinemia. Early identification and monitoring of blood glucose are essential to prevent neurodevelopmental complications.

• Tachypnea of the newborn: The newborn demonstrates increasing respiratory rates (68 → 76/min) with grunting and mild intercostal retractions. These signs indicate transient tachypnea of the newborn, commonly seen after cesarean birth due to delayed clearance of fetal lung fluid. Continuous respiratory monitoring and supportive care are required to prevent hypoxemia or respiratory distress.

Rationale for incorrect choices

• Tachycardia: Although the newborn’s heart rate is slightly on the higher end of normal (154–156/min), it remains within the normal range for a newborn (120–160/min). This is not currently indicative of a pathologic condition or immediate risk.

• Bronchopulmonary dysplasia: Bronchopulmonary dysplasia typically occurs in premature infants who require prolonged mechanical ventilation or oxygen therapy. This term does not apply to a full-term newborn with transient tachypnea following cesarean birth.

Rationale for correct choices

• heparin 30 units/kg IV bolus once: The diagnostic ultrasound confirms a thrombus in the right leg, indicating acute DVT. Anticoagulation with heparin is the first-line intervention to prevent clot extension and pulmonary embolism. The lab values (normal platelets, normal INR) show no contraindication to starting anticoagulation.

• acetaminophen 650 mg PO every 4 hr PRN: Acetaminophen is appropriate for managing the client’s pain (rated 6/10) without increasing bleeding risk. NSAIDs such as ibuprofen are avoided in DVT because they can impair platelet function and increase bleeding risk once anticoagulation is initiated.

Rationale for incorrect choices

• initiating fluid restriction: Fluid restriction is typically used in conditions like heart failure or hyponatremia, not DVT. Adequate hydration is beneficial in DVT because it helps maintain blood viscosity and supports circulation without affecting clot stability.

• maintaining the extremity below the level of the heart: Lowering the extremity increases venous pressure and can worsen swelling. For DVT, the extremity is usually elevated to promote venous return and reduce edema, so this option does not align with recommended care.

• administering cold packs to the extremity: Cold therapy can cause vasoconstriction and slow venous blood flow, which may worsen thrombosis. Warm compresses improve circulation but are used cautiously and only with provider guidance.