A full-term infant is admitted to the newborn nursery 2 hours after delivery.The delivery record indicates the mother is positive for human immunodeficiency virus (HIV) and received zidovudine intravenously during labor.
Which action should the nurse implement?

Hypoglycemia is a common concern for newborns with low birth weight. Their glucose reserves are limited, and they have a higher metabolic rate, making them prone to low blood sugar levels.

Choice B rationale

Polycythemia, an increased red blood cell count, is not typically a primary concern based on the measurements given. It is more commonly associated with conditions like delayed cord clamping or maternal diabetes.

Choice C rationale

Hyperthermia is not a primary concern based on the provided measurements. Thermoregulation issues might arise, but initial focus should be on managing glucose levels.

Choice D rationale

Hyperbilirubinemia, or jaundice, can occur in newborns but is not the immediate priority based on the given physical findings. Monitoring and managing blood sugar levels is more critical in the initial hours after birth.

Choice A rationale

Palpating the suprapubic area to assess fetal head position is not relevant to identifying the source of fluid leakage. This technique is used to evaluate fetal engagement in the pelvis, particularly near term, but it does not help in determining whether the fluid leakage is amniotic fluid or urine.

Choice B rationale

Scanning the bladder for urinary retention is unrelated to identifying the nature of fluid leakage. A bladder scan is useful for detecting residual urine volume in the bladder, often post-voiding, and is typically used in cases of urinary retention or post-operative care.

Choice C rationale

Testing the fluid with a nitrazine strip is a standard method to distinguish amniotic fluid from urine or vaginal secretions. Amniotic fluid has a higher pH (usually between 7.0 and 7.5), causing the nitrazine strip to turn blue, whereas urine and vaginal secretions usually have a lower pH, resulting in a yellow or green color on the strip.

Choice D rationale

Inserting a straight urinary catheter to drain the bladder is an invasive procedure that does not directly identify the source of fluid leakage. This technique is typically used to relieve urinary retention or to collect a sterile urine specimen, not for diagnosing amniotic fluid leakage.