A nurse is assisting with the care of a client who is postpartum.

Exhibits

The nurse is collecting data from the client 24 hr later. How should the nurse interpret the findings?

For each finding, click to specify whether the finding is unrelated to the diagnosis, an indication that the client's condition is improving, or an indication that the client's condition is worsening.

A. Seizures. Severe neonatal hypoglycemia can cause seizures due to impaired brain function from inadequate glucose supply. Prolonged or untreated hypoglycemia increases the risk of neurological complications, making seizure activity a serious sign requiring immediate intervention.
B. Jitteriness. Jitteriness or tremors are common early signs of hypoglycemia in newborns. This occurs due to the nervous system's increased excitability when glucose levels are too low to support normal brain function. If jitteriness is observed, blood glucose levels should be checked promptly.
C. Hypertonia. Hypoglycemia is more commonly associated with hypotonia (decreased muscle tone) rather than hypertonia (increased muscle tone). Low glucose levels impair neuromuscular function, leading to lethargy and reduced muscle strength rather than excessive stiffness or rigidity.
D. Hypothermia. Hypoglycemia can interfere with the newborn’s ability to regulate body temperature, leading to hypothermia. Newborns rely on glucose for energy to maintain thermoregulation, and a drop in glucose levels can result in cold stress, further exacerbating hypoglycemia.
E. Lethargy. Lethargy is a common manifestation of neonatal hypoglycemia, as insufficient glucose deprives the brain of its primary energy source. Affected newborns may have poor feeding, weak cry, and decreased responsiveness, all of which indicate the need for prompt glucose monitoring and intervention.

A. Suggest the client apply warm compresses to the affected breast. Warm compresses help relieve pain, improve circulation, and promote milk flow, which can help reduce engorgement and assist in clearing the infection. Frequent breastfeeding or pumping, along with warm compresses, can prevent milk stasis and aid in recovery.
B. Tell the client to apply hydrocortisone ointment to the affected area of the breast. Hydrocortisone ointment is not recommended for mastitis, as it does not treat the infection or relieve symptoms effectively. Mastitis is a bacterial infection that requires antibiotics if severe, and management focuses on continued breastfeeding, warm compresses, and pain relief.
C. Encourage the client to limit oral fluid intake to decrease milk production. Decreasing fluid intake is not recommended, as hydration is essential for milk production and overall recovery. Instead, the client should continue to drink adequate fluids to maintain milk supply and prevent dehydration.
D. Recommend the client avoid wearing a nursing bra until symptoms resolve. A well-fitting, supportive nursing bra can help reduce breast discomfort and prevent further complications. Avoiding a bra may lead to increased breast engorgement and worsening symptoms rather than relief.