Assessment findings of a 4-hour-old newborn include murmur, irregular respiratory rate at 64 breaths/min, heart rate of 150 beats/min with soft murmur, jitteriness, hypotonic, and weak cry. Based on these findings, which action should the nurse implement?

Choice A rationale: Hemoglobin of 10.4 g/dL is slightly below the normal range for non-pregnant women (12-16 g/dL) but may be acceptable postpartum. Mild anemia can cause fatigue but doesn't explain the new-onset headache, dizziness, or elevated blood pressure.

Choice B rationale: Platelet count of 150,000/mm³ is within the normal range (150,000-450,000/mm³). Thrombocytopenia would be a concern if platelets were below 150,000/mm³, as it can cause bleeding, but it doesn't correlate with the client's symptoms.

Choice C rationale: New-onset headache, especially unrelieved by ibuprofen, is concerning. Postpartum preeclampsia can present with a severe headache. The headache, combined with elevated blood pressure, requires further investigation for potential complications like cerebral edema or hypertensive encephalopathy.

Choice D rationale: Vomiting yellow fluid may indicate gastrointestinal distress or bile. In the context of right upper quadrant pain and elevated blood pressure, it raises concerns for conditions like HELLP syndrome or liver involvement. Further evaluation is needed to rule out these possibilities.

Choice E rationale: Right upper quadrant pain can be a symptom of postpartum preeclampsia or HELLP syndrome, where liver enzymes are elevated. Pain in this area combined with other symptoms like headache, nausea, and elevated blood pressure warrants further investigation.

Choice F rationale: Seeing flashing lights is a potential sign of visual disturbances related to severe hypertension or preeclampsia. It can be an indication of impending eclampsia or other complications like retinal detachment or cerebral edema. This symptom must be promptly evaluated.

Choice G rationale: Elevated blood pressure (169/104 mm Hg) is a critical finding. Normal postpartum blood pressure should be below 140/90 mm Hg. Severe hypertension postpartum can lead to complications like preeclampsia, eclampsia, or stroke. Immediate medical evaluation is required.

Choice H rationale: Iron supplementation is common postpartum to address mild anemia and restore iron levels depleted during pregnancy and delivery. While important for recovery, it does not explain the new-onset headache, elevated blood pressure, or other symptoms reported by the client.

Choice A rationale

A blood glucose level should be obtained first to determine if hypoglycemia is the cause of the infant's jitteriness, which is common in large-for-gestational-age infants of diabetic mothers.

Choice B rationale

Feeding glucose water might help if the infant is hypoglycemic, but confirmation of blood glucose levels is necessary before administration to avoid hyperglycemia.

Choice C rationale

Administering oxygen is indicated if there are signs of respiratory distress or cyanosis, which is not the first consideration in a jittery infant.

Choice D rationale

Decreasing environmental stimuli can be helpful for a jittery infant, but assessing and managing potential hypoglycemia is the priority action.