Four hours after the delivery of a healthy neonate of an insulin-dependent (type 1) di-abetic mother, the baby appears jittery, irritable, and has a high-pitched cry. Which nurs-ing action has top priority?
a. Start an intravenous line with D5W.
b. Notify the clinician stat.
c. Document the event in the nurses' notes.
d. Test for blood glucose level.
D
These symptoms are signs of hypoglycemia in the newborn. Permanent damage can occur if glucose is not constantly available to the brain, but it is not common practice to give intra-venous glucose to a newborn. Feeding the infant is preferable because the formula or breast milk will last longer.
It is not common practice to give intravenous glucose to a newborn. Feeding the infant is preferable because the formula or breast milk will last longer.
Test blood glucose level according to agency policy, treat symptoms with standing orders protocol, and notify the physician with the results.
Documentation can wait until the infant has been tested and treated if a problem is present.
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