Exhibit 1. A nurse understands which of the following assessment findings as a priority to indicate that a newborn may be experiencing cold stress and burning brown fat to produce heat? (Select all that apply.).

Choice A rationale:

This response would not be appropriate because it provides incorrect information. Breast milk is already present in the mother's breasts during pregnancy, and the newborn's disinterest in eating is likely due to other factors.

Choice B rationale:

This is the best response because it acknowledges the mother's concern and offers a practical solution to help the newborn latch onto the breast properly. Correct latching is crucial for successful breastfeeding, and once the baby latches on correctly, they are more likely to breastfeed effectively.

Choice C rationale:

While it is true that newborns often experience deep sleep phases, attributing the disinterest in eating solely to deep sleep is not accurate. Offering support and guidance for breastfeeding would be more beneficial.

Choice D rationale:

This response oversimplifies the situation and may not address the actual reason for the newborn's disinterest in feeding. It is essential to help the mother with proper techniques rather than just waking up the baby.

Choice A rationale:

Placing the newborn in a radiant warmer may provide warmth, but it does not address the observed signs of respiratory distress, jitteriness, and lethargy. These signs indicate potential respiratory and neurological issues, which need to be assessed and managed promptly.

Choice B rationale:

Initiating phototherapy is not appropriate for the observed signs of respiratory distress, jitteriness, and lethargy. Phototherapy is used to treat neonatal jaundice caused by elevated bilirubin levels, which is not evident from the given information.

Choice C rationale:

The nurse should obtain blood glucose by heel stick to assess the newborn's blood sugar levels. The signs of jitteriness and lethargy may be indicative of hypoglycemia (low blood sugar), which is common in newborns. Early detection and intervention are crucial to prevent complications and ensure the baby's well-being.

Choice D rationale:

Measuring the newborn's blood pressure is not the priority at this moment. The observed signs suggest respiratory distress and potential hypoglycemia, which need immediate attention. Blood pressure assessment may be important later on, but it is not the first action the nurse should take based on the given information.