A nurse is assisting with the care of a 28-year-old female client who gave birth 3 days ago in the maternal newborn unit.

Exhibits

Complete the diagram by selecting from the choices below to specify what condition the client is most likely experiencing, 2 actions the nurse should take to address that condition, and 2 parameters the nurse should monitor to assess the client's progress.

Hypoglycemia is most likely given the newborn's jitteriness, weak cry, and mottled extremities, all of which are signs of low blood sugar. The newborn's large birth weight (4,366 g) further increases the risk of hypoglycemia. Immediate feeding is crucial to increase blood sugar levels, and phototherapy can help manage any potential jaundice, which is often associated with hypoglycemia.

Feeding the newborn is essential to provide glucose and stabilize blood sugar levels. Monitoring phototherapy ensures effective treatment of jaundice, which often coexists with hypoglycemia in newborns.

Assessing skin integrity is necessary to prevent complications from jaundice and ensure proper phototherapy response. Monitoring bilirubin levels helps track jaundice severity and the effectiveness of treatment.

Kernicterus, a severe form of jaundice, is less likely because the newborn's symptoms primarily indicate hypoglycemia. Neonatal Abstinence Syndrome, due to maternal drug use, typically involves different symptoms such as irritability, excessive crying, and poor feeding. Congenital Syphilis is ruled out as the mother was treated and tests for syphilis are negative.

High blood pressure during pregnancy can indicate preeclampsia, a potentially dangerous condition requiring prompt intervention. Headache is a common symptom associated with preeclampsia and can indicate worsening condition.

1. Addressing blood pressure is crucial to prevent complications such as eclampsia or organ damage.
2. Monitoring the headache is necessary because it may signal increased intracranial pressure or severe hypertension, both of which need immediate attention.
3. Elevated liver enzymes (AST 200 units/L) indicate potential liver involvement, a severe aspect of preeclampsia known as HELLP syndrome.
4. Keeping a close eye on liver enzymes helps in assessing the progression and severity of preeclampsia and potential liver damage.

Heart rate and respiratory rate are within normal ranges, so they are less immediately concerning. Oxygen saturation is also normal, indicating adequate oxygenation. The headache and elevated liver enzymes are more urgent indicators of severe preeclampsia complications.