A nurse is caring for a newborn who exhibits signs of diaphoresis, jitteriness, and lethargy.Which of the following actions should the nurse take?

Place the newborn in a radiant warmer.

Monitor the newborn's blood pressure.

Initiate phototherapy.

Obtain blood glucose by heel stick.

Answer and Explanation

The Correct Answer is D

Choice A rationale

Placing the newborn in a radiant warmer is appropriate for managing hypothermia but does not directly address the signs of diaphoresis, jitteriness, and lethargy, which are indicative of hypoglycemia.

Choice B rationale

Monitoring the newborn's blood pressure is not the primary action needed for signs of hypoglycemia. The immediate need is to check blood glucose levels and address any hypoglycemia.

Choice C rationale

Initiating phototherapy is a treatment for hyperbilirubinemia (jaundice) and is not related to the signs of diaphoresis, jitteriness, and lethargy seen in hypoglycemia.

Choice D rationale

Obtaining blood glucose by heel stick is the correct action as the signs of diaphoresis, jitteriness, and lethargy are indicative of hypoglycemia. Checking blood glucose levels will help in diagnosing and managing the condition.

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Correct Answer is B

Explanation

A. "I will try drinking an herbal tea to reduce the engorgement.”. B. "I will apply warm compresses 20 minutes before feeding.”. C. "I will let my baby drain one breast at each feeding.”. D. "I will feed my baby every 3-4 hours.”.

Correct Answer is B

Explanation

Choice A rationale

Herbal tea is not scientifically proven to reduce breast engorgement and may not be effective.

Choice B rationale

Warm compresses applied before feeding help to soften the breasts, making it easier for the baby to latch and reducing engorgement.

Choice C rationale

Letting the baby drain one breast completely at each feeding can help prevent engorgement but is not specifically for managing existing engorgement.

Choice D rationale

Feeding every 3-4 hours may not be frequent enough to prevent engorgement, especially in the early days of breastfeeding.

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A nurse is caring for a newborn who exhibits signs of diaphoresis, jitteriness, and lethargy.Which of the following actions should the nurse take?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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