A nurse is caring for a patient with diabetes and plans to administer regular insulin subcutaneously before breakfast at 0800.
After checking the patient’s morning glucose level, what action should the nurse take?

Choice A rationale

Hypoglycemia is a common complication in newborns, especially those who are 8 hours old. The newborn’s body has not yet fully developed the ability to regulate blood sugar levels, leading to hypoglycemia.

Choice B rationale

Neonatal abstinence syndrome is typically seen in newborns exposed to addictive illegal or prescription drugs while in the mother’s womb. Without additional context, it’s not clear if this applies to the newborn in question.

Choice C rationale

Hyperbilirubinemia, or jaundice, is a condition that can occur in newborns, usually a few days after birth. However, it’s less likely to develop within the first 8 hours of life.

Choice D rationale

Drug withdrawal symptoms are similar to neonatal abstinence syndrome and occur in newborns who have been exposed to certain drugs while in the womb. Again, without additional context, it’s not clear if this applies to the newborn in question.

Choice A rationale

Assessing the amniotic fluid is important after rupture of membranes, but it is not the immediate priority. The nurse should first ensure the safety of the mother and baby.

Choice B rationale

Walking the patient to the bathroom is not the immediate priority. After rupture of membranes, the patient should be assisted back to bed to prevent cord prolapse.

Choice C rationale

Calling and informing the healthcare provider is important, but it is not the first action. The nurse should first assist the patient back to bed and initiate fetal monitoring.

Choice D rationale

Assisting the patient back to bed and initiating fetal monitoring is the correct action. After rupture of membranes, the priority is to assess the fetal heart rate for any signs of distress, such as bradycardia, which could indicate cord prolapse.