A nurse observes circumoral cyanosis in an infant who is choking.
Which of the following actions should the nurse take?

Choice A rationale: Administering intravenous dextrose as prescribed is crucial to rapidly raise the newborn's blood glucose level from the critically low value of 35 mg/dL. This intervention addresses the immediate risk of hypoglycemia and helps stabilize the newborn's metabolic status.

Choice B rationale: Warming the newborn using skin-to-skin contact promotes thermoregulation, which is essential for maintaining body temperature and overall stability. Keeping the newborn warm supports metabolic processes and aids in reducing the risk of hypoglycemia and other complications.

Choice C rationale: Administering phototherapy immediately is not necessary unless bilirubin levels are significantly elevated. The primary concern here is hypoglycemia, not hyperbilirubinemia.

Choice D rationale: Monitoring blood glucose levels every 30 minutes ensures that the interventions to correct hypoglycemia are effective. Frequent monitoring helps identify any need for further adjustments to treatment.

Choice E rationale: Administering antibiotics to treat suspected neonatal sepsis is not indicated based on the current symptoms and diagnostic results. The primary issue is hypoglycemia, which requires prompt correction.

Choice A rationale

While acknowledging that hitting a child is wrong is important, the nurse must use therapeutic communication techniques to support the adolescent. Directly stating that the parent was wrong may cause the adolescent to feel defensive or ashamed, and it may not be the most effective way to provide emotional support. The goal is to create a safe and trusting environment where the adolescent feels comfortable discussing their experiences. The nurse should focus on providing empathetic and non-judgmental support to help the adolescent process their feelings and access appropriate resources.

Choice B rationale

Telling the adolescent not to disclose their abuse to anyone else unless it is okay by them is inappropriate and goes against the principles of safeguarding and mandatory reporting. Healthcare professionals have a duty to protect vulnerable individuals and report suspected abuse to the appropriate authorities. This response could inadvertently discourage the adolescent from seeking help or disclosing further information. It is essential to follow protocols for reporting abuse while ensuring the adolescent feels supported and understands that the nurse is taking steps to ensure their safety.

Choice C rationale

Reassuring the adolescent that the abuse is not their fault is an important aspect of providing emotional support and validation. Victims of abuse often struggle with feelings of guilt, shame, and self-blame. By explicitly stating that it is not their fault, the nurse helps to alleviate these feelings and reinforces that the adolescent is not to blame for the abusive behavior. This response aligns with principles of trauma-informed care and helps to build a trusting relationship between the nurse and the adolescent, which is crucial for their emotional healing.

Choice D rationale

Implying that the other parent did nothing to stop the abuse can lead to further emotional distress for the adolescent and may cause feelings of betrayal or abandonment. This response may not provide the necessary support or validation the adolescent needs in that moment. The nurse should focus on addressing the immediate emotional needs of the adolescent and providing reassurance and support. Discussions about the roles of other family members should be handled delicately and may require the involvement of counseling or social services.