A nurse is preparing to obtain a blood sample from a newborn's heel. In what order should the nurse perform the procedure? (Move the steps into the box on the right, placing them in the selected order of performance. Use all the steps.)

Explanation

Choice A Reason:

Peripartum cardiomyopathy is a form of heart failure that occurs during the last month of pregnancy or the first few months postpartum. Fluid restriction is often necessary to prevent fluid overload, which can exacerbate heart failure symptoms. By restricting fluid intake, the nurse helps manage the client's fluid balance and reduces the risk of worsening heart failure.

Choice B Reason:

Administering an IV bolus of fluids, such as lactated Ringer's, can increase the client's fluid volume, which is contraindicated in clients with heart failure, including peripartum cardiomyopathy. This could worsen the condition by increasing the workload on the already compromised heart.

Choice C Reason:

Assessing blood pressure is important in monitoring the client's cardiovascular status, but assessing it twice daily may not be sufficient for a client with peripartum cardiomyopathy, especially in the acute postpartum period. Blood pressure should be monitored more frequently, and any significant changes should be promptly addressed.

Choice D Reason:

Obtaining a prescription for misoprostol is incorrect. Misoprostol is a medication used for various purposes, including the prevention and treatment of postpartum hemorrhage. However, it is not a specific treatment for peripartum cardiomyopathy. The focus in peripartum cardiomyopathy management is on cardiac support and stabilization.

Explanation

Choice A Reason:

Abdominal distention is not a typical manifestation of hypoglycemia in newborns. It may indicate other issues such as gastrointestinal discomfort, intestinal obstruction, or excessive gas accumulation.

Choice B Reason:

Jitteriness is correct. Hypoglycemia in newborns can occur, particularly if the mother had gestational diabetes mellitus (GDM). Jitteriness is one of the common manifestations of hypoglycemia in newborns. Other signs may include poor feeding, lethargy, sweating, cyanosis, respiratory distress, and seizures.

Choice C Reason:

Petechiae are small, pinpoint hemorrhages in the skin caused by bleeding under the skin. While petechiae can occur due to various reasons, including neonatal sepsis or birth trauma, they are not typically associated with hypoglycemia.

Choice D Reason:

Increased muscle tone is incorrect. Hypoglycemia in newborns usually presents with decreased muscle tone rather than increased muscle tone. Increased muscle tone is more commonly associated with conditions such as hypocalcemia or central nervous system disorders.