The nurse is assessing a 40-week small for gestational age (SG

Choice A rationale

Placing the newborn in a radiant warmer is appropriate for managing hypothermia but does not directly address the signs of diaphoresis, jitteriness, and lethargy, which are indicative of hypoglycemia.

Choice B rationale

Monitoring the newborn's blood pressure is not the primary action needed for signs of hypoglycemia. The immediate need is to check blood glucose levels and address any hypoglycemia.

Choice C rationale

Initiating phototherapy is a treatment for hyperbilirubinemia (jaundice) and is not related to the signs of diaphoresis, jitteriness, and lethargy seen in hypoglycemia.

Choice D rationale

Obtaining blood glucose by heel stick is the correct action as the signs of diaphoresis, jitteriness, and lethargy are indicative of hypoglycemia. Checking blood glucose levels will help in diagnosing and managing the condition.

Choice A rationale: Initiating phototherapy is essential for treating neonatal jaundice. Phototherapy helps to break down bilirubin in the skin, reducing serum bilirubin levels and preventing complications such as kernicterus. It is a common and effective treatment for elevated bilirubin levels in newborns.

Choice B rationale: Administering intravenous dextrose addresses the newborn's low blood glucose level. Hypoglycemia in newborns can lead to severe neurological complications if not treated promptly. Dextrose administration helps stabilize blood glucose levels, improving the newborn's overall condition.

Choice C rationale: Performing a lumbar puncture is not indicated in this scenario. The newborn's symptoms and diagnostic results do not suggest a need for this procedure. Lumbar punctures are typically performed to diagnose conditions such as meningitis, which is not evident here.

Choice D rationale: Encouraging frequent breastfeeding or formula feeding helps in reducing bilirubin levels and maintaining blood glucose levels. Adequate feeding promotes regular bowel movements, aiding in the excretion of bilirubin, and ensures the newborn receives necessary nutrients to stabilize blood glucose levels.

Choice E rationale: Administering naloxone is used for opioid withdrawal, which is not relevant in this case. The newborn's symptoms do not indicate opioid exposure, so this intervention is unnecessary.