A nurse is caring for a newborn and observes signs of diaphoresis, jitteriness, and lethargy. Which of the following actions should the nurse take?
A.
Obtain blood glucose by heel stick.
B.
Initiate phototherapy.
C.
Monitor the newborn’s blood pressure.
D.
Place the newborn in a radiant warmer.
The Correct answer and Explanation is:
Correct Answer: A. Obtain blood glucose by heel stick.
Explanation:
In a newborn presenting with diaphoresis (excessive sweating), jitteriness (shaking or trembling), and lethargy (extreme fatigue or drowsiness), it is essential to first assess for hypoglycemia (low blood sugar). These symptoms are common indicators of hypoglycemia in neonates.
1. Diaphoresis: Excessive sweating can be a sign of an underlying issue such as low blood sugar. In newborns, it often indicates that the body is trying to regulate an imbalance or stress.
2. Jitteriness: This is a characteristic sign of hypoglycemia in neonates. Jitteriness or tremors are often caused by low glucose levels, as glucose is a primary energy source for the brain and muscles.
3. Lethargy: A lethargic newborn may be experiencing a significant drop in blood glucose levels. Lethargy is a serious sign that the newborn might be suffering from a metabolic imbalance that needs urgent attention.
Given these symptoms, the nurse should prioritize obtaining a blood glucose level through a heel stick. This test is crucial for diagnosing or ruling out hypoglycemia, which is a common and treatable condition. Early detection and management are essential to prevent potential complications such as seizures, developmental delays, or other severe outcomes.
Why not the other options?
- B. Initiate phototherapy: Phototherapy is typically used for newborns with jaundice (elevated bilirubin levels), not for symptoms like diaphoresis, jitteriness, and lethargy.
- C. Monitor the newborn’s blood pressure: While monitoring blood pressure is important, these specific symptoms more strongly indicate a potential issue with blood glucose levels rather than blood pressure.
- D. Place the newborn in a radiant warmer: Radiant warmers are used to maintain body temperature, but the symptoms described are more indicative of a glucose imbalance rather than a temperature regulation issue.
By promptly checking the blood glucose level, the nurse can quickly address any hypoglycemia and take appropriate actions to stabilize the newborn’s condition, ensuring proper care and preventing further complications.