A nurse is caring for a 37-year-old female client in the labor and delivery unit. The client is in early labor and presents with contractions and reports feeling fetal movement.

The nurse should anticipate a provider's prescription for

______

due to the client’s

________

.

Condition: Hypoglycemia

Actions: Feed the newborn immediately with breastmilk or formula. Obtain a capillary blood glucose reading.

Parameters: Blood glucose levels. Respiratory effort.

Rationale for correct condition: The newborn's blood glucose level is significantly low at 30 mg/dL. Symptoms like jitteriness, rapid respirations, and mottling are indicative of hypoglycemia. The newborn has not been fed since birth, which can cause low blood sugar. The temperature is slightly low, another sign of hypoglycemia. Immediate feeding can help stabilize blood glucose levels.

Rationale for actions: Feeding the newborn will raise the blood glucose level quickly. A capillary blood glucose reading is crucial to confirm the diagnosis and monitor effectiveness of the treatment. IV glucose might be necessary if the newborn cannot feed or if the blood glucose does not stabilize. Phototherapy and a radiant warmer are not required unless other conditions are present.

Rationale for parameters: Monitoring blood glucose levels ensures the newborn's hypoglycemia is addressed effectively. Respiratory effort must be monitored to ensure that the rapid respirations normalize with the correction of blood glucose levels. Serum bilirubin levels and skin integrity are not directly related to hypoglycemia.

Rationale for incorrect conditions: Congenital heart defect would likely present with more severe respiratory distress or cyanosis, not just acrocyanosis and jitteriness. Neonatal sepsis would present with signs of infection like fever or lethargy, neither of which is observed here. Neonatal abstinence syndrome would include symptoms such as irritability, high-pitched crying, and feeding difficulties, not specifically observed in this newborn.

Choice A rationale

Moderate lochia rubra is normal postpartum bleeding and does not indicate a worsening condition.

Choice B rationale

Decreased pain suggests recovery rather than deterioration.

Choice C rationale

A temperature of 38.4°C (101°F) suggests a potential infection or inflammatory process, indicating a worsening condition.

Choice D rationale

An elevated WBC count indicates an immune response, which may suggest infection or inflammation, pointing to a worsening condition. .