The nurse is caring for a 2-hour-old newborn whose mother is diabetic. The nurse assesses that the newborn is experiencing tremors. What nursing action has the highest priority?
1. Obtain a blood calcium level.
2. Take the newborn's temperature.
3. Obtain a bilirubin level.
4. Place a pulse oximeter on the newborn.
1
Rationale:
1. Tremors are the classical sign for hypocalcemia. Diabetic mothers tend to have decreased serum magnesium levels at term. This could cause secondary hypoparathyroidism in the infant.
2. Body temperature also might be necessary to monitor, but does not present with tremors in the newborn.
3. Bilirubin level also might be necessary to monitor, but does not present with tremors in the newborn.
4. Oxygen saturation also might be necessary to monitor, but does not present with tremors in the newborn.
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