The nurse is reviewing a chart in the newborn nursery. An RN was ordered to take blood glucose (BG) recordings on a newborn delivered that morning. BG readings are as follows: 50 mg/dL at 7:00 a.m.; 57 mg/dL at 10:00 a.m.; 62 mg/dL at 12:00 p.m.; 67 mg/dL at 2:00 p.m.; and 68 at 4:00 p.m. What action should the nurse perform with these recordings?

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.

Correct Answer: D

Rationale: The correct answer is D: Cord blood gas. When the mother has Rh type O blood and the newborn's Apgar score is low, it indicates potential oxygenation issues during birth. Cord blood gas analysis is crucial to assess the newborn's oxygenation status and acid-base balance. A low Apgar score suggests the need to evaluate the newborn's respiratory and metabolic functions, which can be done through cord blood gas analysis. A: Cardiac enzymes - Not relevant in this scenario as the focus is on oxygenation and respiratory function, not cardiac issues. B: Blood glucose - Not directly related to the situation described, as low Apgar score and Rh blood type are more indicative of oxygenation and potential Rh incompatibility. C: Electrolyte panel - While electrolyte imbalance is important, cord blood gas analysis provides more immediate information on oxygenation and acid-base balance, which are crucial in low Apgar score situations.

Correct Answer: C

Rationale: The correct answer is C. Placing the infant directly on the scale for weight measurement is incorrect as it can lead to inaccurate results due to factors like clothing or diaper weight. The correct method is to weigh the infant without clothing and then subtract the weight of the diaper. A: Heel stick method for blood glucose is appropriate. B: Placing an infant on phototherapy after swaddling is acceptable practice. D: Performing Ortolani and Barlow maneuvers in the supine position is also correct.

Correct Answer: D

Rationale: The correct answer is D: Decline in fetal erythrocytes around 2 months of age. Physiological anemia of infancy occurs around 2-3 months of age due to a natural decline in fetal erythrocytes. This decline is a normal process as the infant's body adjusts to extrauterine life. A: Gestational diabetes leading to LGA in the infant is unrelated to physiological anemia. B: Hypervolemia from maternal bleeding is not a known cause of physiological anemia in infants. C: Red blood cell death every 15 days is not a recognized physiological process leading to anemia in infants. In summary, the correct answer is D because it directly addresses the natural decline in fetal erythrocytes that occurs around 2 months of age, leading to physiological anemia of infancy. The other choices are incorrect as they do not provide a relevant explanation for the occurrence of physiological anemia in infants.