The parents of a male newborn have signed an informed consent for circumcision. Which priority intervention should the nurse implement upon completion of the circumcision?

Rationale for correct condition: Hypoglycemia in neonates can present with jitteriness, low body temperature, and poor feeding. Normal blood glucose levels for neonates range from 40-60 mg/dL. The Ballard maturity rating of 37 weeks indicates that the neonate may have an immature glucose metabolism. Early recognition and treatment are crucial to prevent complications.

Rationale for correct actions:

• Giving dextrose solution orally quickly increases blood glucose levels. This provides an immediate source of glucose to the neonate.
• Performing a heel stick for blood glucose testing allows for accurate monitoring of glucose levels. Continuous assessment ensures timely intervention.

Rationale for correct parameters:

• Blood glucose levels: Monitoring ensures that the neonate maintains normal glucose levels (40-60 mg/dL). This helps prevent hypoglycemia-related complications.
• Temperature: Neonates with hypoglycemia often have low body temperature. Monitoring temperature aids in detecting and addressing hypothermia.

Rationale for incorrect conditions:

• Altered respiratory function: The neonate has normal respiratory rate and heart rate.
• Thermoregulation: Although temperature is low, the jitteriness is more indicative of hypoglycemia.
• Sepsis: No signs of infection such as fever or elevated white blood cell count are present.

Rationale for incorrect actions:

• Provide manual breaths with a bag-valve mask: Not necessary as the neonate's respiratory rate is normal.
• Administer intravenous antibiotics: No signs of infection or sepsis.
• Place the neonate under a radiant warmer: This addresses temperature but not blood glucose levels.

Rationale for incorrect parameters:

• Respiratory rate: Normal, does not indicate hypoglycemia.
• Oxygen saturation: No signs of respiratory distress.
• Bilirubin levels: Not relevant to the current symptoms.

Choice A rationale

Explaining procedures is important for patient understanding and consent, but it does not directly stabilize the client's condition during an eclamptic seizure.

Choice B rationale

Treating nausea can provide symptomatic relief but does not address the primary concerns of airway protection, seizure control, and hemodynamic stability in eclamptic patients.

Choice C rationale

Ensuring side rails are padded prevents injury during seizures by providing a protective barrier, reducing the risk of trauma from uncontrolled movements.

Choice D rationale

Assisting with breast pumping does not directly impact the stabilization of an eclamptic patient. The priority is managing seizures and ensuring patient safety.

Choice E rationale

Evaluating blood pressure frequently allows for early detection of hypertension or hypotension, guiding appropriate interventions to maintain hemodynamic stability and prevent complications.

Choice F rationale

Evaluating for headache is important for assessing potential complications of eclampsia, such as intracranial hypertension, but does not directly stabilize the patient during an acute seizure.

Choice G rationale

Assessing deep tendon reflexes helps monitor neurological status and the effectiveness of magnesium sulfate therapy, guiding further treatment decisions to prevent complications.

Choice H rationale

Minimizing visitors reduces environmental stimuli, which can help lower stress levels and prevent triggering additional seizures, contributing to the patient's stabilization.