A newborn’s blood glucose level is recorded at 42 mg/dL. What is the next step the nurse should take?

Correct Answer: C

Rationale: The correct answer is C: Report the blood glucose level to the practitioner. A blood glucose level of 42 mg/dL in a newborn is considered low and may indicate hypoglycemia. It is important to involve the practitioner immediately for further evaluation and management. Reporting to the practitioner ensures timely intervention and appropriate treatment. Summary: A: Recording the number in the chart without taking any action may lead to delayed intervention. B: Immediately asking the mother to feed the newborn may not address the underlying cause of the low blood glucose level. D: Observing for hypoglycemia is important but reporting to the practitioner should be prioritized for proper management.

Correct Answer: B

Rationale: The correct answer is B: Periodic episodes of grunting during expiration. This warrants further investigation as grunting during expiration is a sign of respiratory distress in newborns, indicating potential respiratory compromise. It can be a sign of underlying lung pathology or inadequate oxygenation. It is important to assess and address this promptly to prevent further deterioration. Incorrect choices: A: Irregular patterns of breathing with periods of apnea lasting 5 seconds - While apnea can be concerning, it is common in newborns. This alone may not warrant immediate further investigation. C: Breathing at a rate of 45 breaths per minute - A respiratory rate of 45 breaths per minute can be within normal range for a newborn. It may not be abnormal unless accompanied by other signs of distress. D: Mild sternal retractions - Sternal retractions can be a sign of increased work of breathing, but mild retractions alone may not be as concerning as grunting during expiration.

Correct Answer: D

Rationale: The correct answer is D: Breastfeeding. Newborns exclusively breastfed are at risk of hypoglycemia due to delayed milk production, inadequate feeding, and poor latching. Prematurity (A) and being large for gestational age (B) can increase the risk, but they are not primary causes. Cold stress (C) can contribute, but it's not a direct risk factor for hypoglycemia in newborns. By process of elimination and understanding the physiological effects of breastfeeding on newborn glucose levels, choice D is the most relevant risk factor.

Correct Answer: D

Rationale: The correct answer is D because elevated bilirubin levels in newborns indicate jaundice, which can lead to complications if not treated promptly. Phototherapy helps break down bilirubin and is the first-line treatment for neonatal jaundice. Applying phototherapy as per hospital protocol is essential to decrease bilirubin levels. Notifying the physician is also crucial for ongoing monitoring and management. Choice A (Place the patient NPO and notify a physician) is incorrect because NPO status is not necessary for managing neonatal jaundice, and phototherapy is the primary intervention. Choice B (Weigh the patient to see if weight loss has occurred) is incorrect because weight loss is not directly related to elevated bilirubin levels in newborns. Choice C (Take the newborn’s vital signs and report to the physician) is incorrect because while vital signs are important, the immediate intervention for elevated bilirubin levels is phototherapy to prevent complications.

Correct Answer: D

Rationale: The correct answer is D: Review orders for the timing of next BG reading. This is the correct action because the nurse should follow the protocol and guidelines set by the healthcare provider regarding the frequency and timing of blood glucose monitoring in newborns. By reviewing the orders, the nurse ensures that the newborn's blood glucose levels are monitored appropriately and at the right intervals. This helps in maintaining the newborn's health and identifying any potential issues promptly. Other choices are incorrect: A: Notify the physician immediately that the BG readings on this newborn are low - Premature action without assessing the situation or following protocol. B: Immediately give the newborn glucose water - Inappropriate and potentially harmful intervention without proper evaluation. C: Confirm the readings with the laboratory - Unnecessary step as the nurse can follow the established protocol without involving the laboratory unnecessarily.