The nurse is assessing a 40-week small for gestational age (SG

Choice A rationale

• Normal neonatal glucose: >45 mg/dL (ideally 50–110 mg/dL).

• A level of 40 is low → risk for hypoglycemia complications (seizures, brain injury).

While it is important to monitor glucose levels, a reading of 40 mg/dL is low and requires immediate attention. Waiting 4 hours could allow the newborn's condition to deteriorate further. Hypoglycemia in newborns can lead to serious complications if not treated promptly.

Choice B rationale

Assessing for hypothermia is essential, but it is not the first priority when a newborn has low blood glucose levels. Immediate steps should be taken to address the hypoglycemia to prevent further complications, as it is a more immediate threat to the newborn's health.

Choice C rationale

Notifying the physician on call is the correct priority intervention. A blood glucose level of 40 mg/dL is concerning, and prompt medical intervention is necessary. The physician can order appropriate treatment to stabilize the newborn's glucose levels and prevent potential complications.

Choice D rationale

Re-evaluating the blood serum glucose is important but comes after initiating immediate intervention. Continuous monitoring should follow initial treatment to ensure the newborn's glucose levels stabilize. Immediate action is crucial to address the hypoglycemia effectively.

Choice A rationale: Initiating phototherapy is essential for treating neonatal jaundice. Phototherapy helps to break down bilirubin in the skin, reducing serum bilirubin levels and preventing complications such as kernicterus. It is a common and effective treatment for elevated bilirubin levels in newborns.

Choice B rationale: Administering intravenous dextrose addresses the newborn's low blood glucose level. Hypoglycemia in newborns can lead to severe neurological complications if not treated promptly. Dextrose administration helps stabilize blood glucose levels, improving the newborn's overall condition.

Choice C rationale: Performing a lumbar puncture is not indicated in this scenario. The newborn's symptoms and diagnostic results do not suggest a need for this procedure. Lumbar punctures are typically performed to diagnose conditions such as meningitis, which is not evident here.

Choice D rationale: Encouraging frequent breastfeeding or formula feeding helps in reducing bilirubin levels and maintaining blood glucose levels. Adequate feeding promotes regular bowel movements, aiding in the excretion of bilirubin, and ensures the newborn receives necessary nutrients to stabilize blood glucose levels.

Choice E rationale: Administering naloxone is used for opioid withdrawal, which is not relevant in this case. The newborn's symptoms do not indicate opioid exposure, so this intervention is unnecessary.