A 26-week gestational primigravida who is carrying twins is seen in the clinic today. Her fundal height is measured at 29 cm. Based on these findings, which action should the nurse implement?

Choice A rationale

Documenting the finding in the medical record is routine, but it does not address the potential concern of the fundal height discrepancy, which may indicate a need for further evaluation.

Choice B rationale

Scheduling a biophysical profile is crucial to assess the well-being of the fetuses, especially given the discrepancy in fundal height, which could indicate issues such as growth restriction or polyhydramnios.

Choice C rationale

Requesting another nurse to measure the fundus might help verify the measurement but does not address the potential underlying issue, which requires further assessment like a biophysical profile.

Choice D rationale

Notifying the healthcare provider is necessary, but it is more appropriate to first schedule a biophysical profile to gather comprehensive information on the fetal well-being before consulting the provider.

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.