A nurse is completing the admission assessment of a newborn.
Which of the following anatomical landmarks should the nurse use when measuring the newborn’s chest circumference?

1. “The glans penis will appear red and have a yellow crust as it heals. Do not remove this.”
   • Essential: This is a normal part of the healing process.
2. “Ensure the diaper is really tight to keep the gauze attached to the penis.”
   • Contraindicated: The diaper should be loose to avoid pressure on the circumcision site.
3. “Notify your pediatrician if your baby has not voided in 24 hours.”
   • Essential: This could indicate a problem that needs medical attention.
4. “Coat the glans penis with petroleum jelly and cover with gauze.”
   • Essential: This helps prevent the diaper from sticking to the circumcision site and aids in healing.
5. “Check for bleeding every 4 hours for the first 24 hours and notify your pediatrician if there is bleeding at the circumcision site.”
   • Essential: Monitoring for bleeding is crucial to ensure there are no complications.

Choice A rationale

Given the neonate’s symptoms and critically low blood glucose level (30 mg/dL), the most urgent action is to address the hypoglycemia. Therefore, the nurse shouldadminister a bolus of intravenous glucose (Option A). This immediate intervention is crucial to stabilize the neonate and prevent further complications associated with hypoglycemia.

Choice B rationale

While monitoring blood glucose levels is important, waiting 30 minutes to reassess without immediate intervention could allow the hypoglycemia to worsen, potentially leading to severe complications such as seizures or brain damage. Immediate treatment is necessary to stabilize the neonate..

Choice C rationale

Although feeding can help increase blood glucose levels, the neonate’s current symptoms (jitteriness, poor feeding, weak cry, and irritability) suggest that they may not be able to effectively feed. Additionally, the blood glucose level is critically low and requires more rapid correction than feeding alone can provide..

Choice D rationale

While maintaining an appropriate body temperature is important, the neonate’s temperature (36.1°C) is not critically low. The primary concern here is the hypoglycemia, which needs to be addressed immediately. Placing the neonate under a radiant warmer does not directly address the low blood glucose level..