Three hours after birth, a newborn becomes jittery and tachypneic. What should the nurse do first?
Explanation & Rationale
A. Obtain a capillary glucose level: The symptoms of jitteriness and tachypnea in a newborn could be indicative of hypoglycemia, so the first action should be to assess the glucose level to determine if hypoglycemia is the cause. B. Feed 30 mL of 10% dextrose in water: While providing dextrose may be necessary if hypoglycemia is confirmed, assessing the glucose level should be done first to guide appropriate treatment. C. Wrap tightly in a warm blanket: While keeping the newborn warm is important, it is not the first action to take in this scenario where the newborn is displaying signs of possible hypoglycemia. D. Encourage the mother to breastfeeD Breastfeeding may help increase the newborn's glucose level, but the priority is to assess the glucose level first to determine if hypoglycemia is present.