An infant of a Diabetic Mother (IDM) has a blood glucose of 60 upon admission to the well-baby nursery. Which of the following is an appropriate nursing action?
Select one:

Choice A Reason: Hyperglycemia and increased appetite. This is an incorrect answer that describes symptoms of diabetes mellitus, not sepsis. Diabetes mellitus is a chronic metabolic disorder where the body cannot produce or use insulin effectively, which results in high blood glucose levels and impaired glucose tolerance. Diabetes mellitus can affect newborns if the mother has pre-existing or gestational diabetes, which can cause macrosomia, hypoglycemia, or congenital anomalies.

Choice B Reason: Increased urinary output and spitting up mucous. This is an incorrect answer that indicates normal or benign conditions, not sepsis. Increased urinary output is a normal finding in newborns, as they eliminate the excess fluid that was accumulated during pregnancy. Spitting up mucous is a common occurrence in newborns, as they clear their airways of amniotic fluid or secretions.

Choice C Reason: Wakefulness and ruddy appearance. This is an incorrect answer that suggests healthy or normal characteristics, not sepsis. Wakefulness is a sign of alertness and responsiveness in newborns, which reflects their neurological development and adaptation. Ruddy appearance is a reddish color of the skin that is normal in newborns, especially in term or post-term infants, which indicates adequate oxygenation and hemoglobin levels.

Choice D Reason: Temperature instability and lethargy. This is because temperature instability and lethargy are common signs of sepsis in newborns, which indicate systemic infection and inflammation. Sepsis is a life-threatening condition where the body's response to infection causes tissue damage, organ failure, or death. Sepsis can occur in newborns due to maternal, fetal, or neonatal factors, such as chorioamnionitis, premature rupture of membranes, prolonged labor, invasive procedures, or bacterial colonization.

Choice A Reason: Homans' sign. This is an incorrect answer that refers to a different sign that is not related to pregnancy. Homans' sign is a sign of deep vein thrombosis (DVT) that occurs when there is pain or discomfort in the calf or popliteal region when the foot is dorsiflexed. Homans' sign can be elicited by passive or active movement of the foot, but it is not a reliable or specific indicator of DVT.

Choice B Reason: Chadwick's sign. This is an incorrect answer that refers to a different sign of pregnancy that affects the color of the cervix, not the texture. Chadwick's sign is a sign of pregnancy that refers to the bluish or purplish discoloration of the cervix, vagina, and vulva due to increased blood flow and congestion. Chadwick's sign can be observed by visual inspection of the cervix during the first prenatal visit, usually around 6 to 8 weeks of gestation.

Choice C Reason: Goodell's sign. This is because Goodell's sign is a sign of pregnancy that refers to the softening of the cervix due to increased vascularity and edema. Goodell's sign can be detected by digital examination of the cervix during the first prenatal visit, usually around 6 to 8 weeks of gestation.

Choice D Reason: McDonald's sign. This is an incorrect answer that refers to a different sign of pregnancy that involves the angle of the uterus, not the cervix. McDonald's sign is a sign of pregnancy that refers to the ease of flexing the body of the uterus against the cervix, which creates an angle of 90 degrees or less. McDonald's sign can be assessed by bimanual examination of the uterus during the first prenatal visit, usually around 7 to 8 weeks of gestation.