A nurse is caring for a 32-year-old female client who is at 28 weeks of gestation,

Exhibits

Complete the diagram by dragging 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.

Choice A rationale
Feeding the newborn 5 to 10 minutes per breast may not be sufficient for the baby to get all the necessary nutrients. It is generally recommended to allow the baby to feed until they naturally let go of the breast.
Choice B rationale
Expecting two to four wet diapers every 24 hours is not accurate for a breastfeeding newborn. A well-fed newborn will typically have at least six wet diapers a day.
Choice C rationale
This is the correct answer. It is generally recommended to allow the baby to feed at least every 3 hours. This ensures that the baby gets enough nutrients and helps stimulate milk production.
Choice D rationale
Offering the newborn 30 mL (1 oz) of water between feedings is not recommended. Breast milk or formula should be the primary source of hydration for a newborn.

• Neonatal hypoglycemia: The newborn’s blood glucose level is 30 mg/dL, which is below the normal range. This, along with the jitteriness, weak cry, and mottled skin with acrocyanosis, suggests the newborn is most likely experiencing neonatal hypoglycemia.
• Actions to take: The nurse should administer a 10% dextrose IV bolus as prescribed by the provider to increase the newborn’s blood glucose levels. The nurse should also monitor the newborn’s blood glucose levels every 30 minutes to ensure they are increasing towards the normal range.
• Parameters to monitor: The nurse should monitor the newborn’s blood glucose levels to ensure they are increasing towards the normal range. The nurse should also monitor the newborn’s heart rate, as tachycardia can be a sign of hypoglycemia. If the newborn’s condition does not improve or worsens, the nurse should notify the healthcare provider immediately.